Investigation of an outbreak with different case scenarios- Phase III - SDL

General Instructions to the students

1. Prepare each case scenario in group of approximately 10 students in each batch. One case scenario for

each group, therefore, the total groups in each batch will be 5 in number.

2. Make PPT for seminar presentation on your respective days of classes scheduled.

3. All the members of each group should slove the questions and present for question and answer session

following the presentation.

4. Marks will be provided out of 5 for each group.

15.05.2023 - Batch A – Roll no. 01 – 49 (copying ppts from other batches is strictly condemned)

Case scenario 1 (Roll no. 01 to 10)

Case scenario 2 (Roll no. 11 to 20)

Case scenario 3 (Roll no. 21 to 30)

Case scenario 4 (Roll no. 31 to 40)

Case scenario 5 (Roll no. 41 to 49)

16.05.2023 - Batch B – Roll no. 50 – 98 (copying ppts from other batches is strictly condemned)

Case scenario 1 (Roll no. 50 – 59)

Case scenario 2 (Roll no. 60 – 69)

Case scenario 3 (Roll no. 70– 79)

Case scenario 4 (Roll no. 80 – 89)

Case scenario 5 (Roll no. 90 – 98)

17.05.2023 - Batch C – Roll no. 99 – 147 (copying ppts from other batches is strictly condemned)

Case scenario 1 (Roll no. 99 – 109)

Case scenario 2 (Roll no. 110 – 119)

Case scenario 3 (Roll no. 120 – 129)

Case scenario 4 (Roll no. 130 – 139)

Case scenario 5 (Roll no. 140 – 147)

Case scenario 1: A community in Baner experienced abdominal cramps, vomiting, with insidious onset

characterized by fever, headache, constipation, malaise, chills, myalgia in a 4–7-day span of time. Health officials

noted that an unusually large number of cases had been reported during a span of several days. It was noted that

all of the disease people had attended a parent-teacher meeting followed by lunch at a local school. In fact, it was

a potluck lunch, and the attendees each brought a dish that they had either prepared at home or purchased. The

source population was obviously the attendees of the lunch, and 58% of the attendees had developed symptoms.

Of these, 45 attendees agreed to complete a questionnaire regarding the foods that they had eaten at the lunch.

The investigators needed to establish which dish was responsible in order to clearly establish the source and to

ensure that appropriate control measures were undertaken.

Questions:

1. What according to you is the disease in question. Is this an outbreak ? If so, how ?

2. Which type of epidemiological study design would you choose to detect this kind of outbreak?

3. About 23 attendees recalled eating the cheese appetizer, and 16 of them subsequently developed

Symptoms. There were 22 attendees who did not recall eating the cheese appetizer, and 9 or these

developed symptoms. Draw a 2 x 2 contingency table, find out the incidence among those who ate and

those who did not eat cheese appetizer.

4. Calculate the Risk Ratio.

5. What is meant by contact tracing. Explain appropriate control measure you would undertake?
Case scenario 2: Dr. X was on casualty duty that day. Mr. Y, 49 years old, presented to Medicine casualty with

high grade fever (3 days), retro-orbital pain, myalgia, and rash. While eliciting detailed history from the patient,

he revealed that there was a history of fever and body ache for his brother and brother’s wife one week back for

which they took treatment in a private hospital. Mr. Y and his four brothers lived in nearby houses in the same

compound (within 300 meters). He took paracetamol on the first two days of fever thinking that he was feverish

as he walked in the rain the previous day.

Questions:

1. As a health professional what do you think about this episode and how do we proceed to investigate

and manage the situation. (Follow steps in investigation of an outbreak)

2. Find out the source of disease transmission. What is “Rapid Response Team” and who all consist of it.

3. Draw an epidemiological triad and accordingly fix the disease in question.

4. List the laboratory investigations to confirm the disease.

5. Measures to control disease transmission and preventive practices in the community.

Case scenario 3: A nurse at a summer camp for adolescents observed an excessive number of people at the camp

seeking help for diarrhoea and/or vomiting during a week in late March. Normally, two or three campers per week

would report to the health office with these symptoms; however, 23 campers and staff sought help in a two-day

span. The nurse reported the increased incidence to the camp manager and the local health department, and the

camp was closed.

Further, Active case finding, and surveillance began after the department of health identified the E. coli positive

well water sample on April 19. A case of gastroenteritis is defined as an illness lasting for more than 24 hours

that includes three or more episodes of diarrhoea, vomiting, or both. The attack had to occur in a camper or staff

member after arriving or leaving the camp during the period from March 1 through April 19. The health

department obtained lists of camp attendees and staff from camp managers and conducted a retrospective cohort

study by administering a telephone questionnaire to 210 out of 277 (76 percent) of individuals. The study

identified 141 cases (67 percent). About 102 people reported diarrhoea (72 percent), 92 reported vomiting (65

percent), and 89 reported stomach cramps (63 percent).

Questions:

1. What education should the nurse provide to campers and staff as they go home?

2. Is this infectious disease a communicable disease? Draw epidemiological triad and explain your answer.

3. Are all the campers and staff at the camp susceptible hosts? Explain your answer.

4 What was the incidence rate among those interviewed? (Use the following formula: total number of

cases divided by the total population eligible.)

5. Did the occurrence of E. coli at the camp meet the definition of an outbreak? Why or why not?

6. Discuss the following question: What roles might a public health specialist assume following report of

a communicable disease outbreak? Explain contact investigation.

Case scenario 4: Baripada is a large municipality located in the district of Mayurbhanj, in the North of Orissa,

close to the border with Jharkhand and West Bengal. The population of Baripada in the late 1990s, the population

size exceeded 100,000. On 8 February 2004, a number of private practitioners from Baripada municipality in

Mayurbhanj district, Orissa, called the Assistant District Medical Officer (Public Health), Mayurbhanj to report

large numbers of patients suffering from acute jaundice in the city. These practitioners reported that these cases

of acute jaundice tended to cluster by households. At the same time, clinical laboratories established in the city

of Baripada reported a large number of specimen submitted for analysis with a working diagnosis of acute

hepatitis. On 9 February 2004, a team of public health workers and supervisors led by Dr Susanta Swain, Field

Epidemiology Training Programme (FETP) scholar from the 2003 cohort reached the city of Baripada to

investigate the outbreak. On the day of the arrival of the team, 21 reports of acute jaundice had been received so

far. under normal circumstances, about eight to 10 cases of such diseases were reported in the city each year.

During the Baripada investigation, the investigators decided to define a case as a combination of (1) loss of

appetite with (2) yellow coloration of conjunctiva or coloured urine that occurred suddenly since 19 January 2004

in a resident of Baripada. The investigators are now about to search for cases systematically in the city of Baripada

so that they can constitute their line listing and describe this outbreak in terms of time, place, and person. The

investigators have now completed the search that led to the identification of 538 cases among which five deaths

for a population of 105,422 persons (attack rate: 5,1 per 1,000 population, case fatality ratio: 0.9%).

When they arrived in Baripada, the team went to the hospital to see some of the affected case-patients and discuss

with the clinicians who had been managing them. They learned that patients presented with fever, malaise and

then with acute jaundice. Urines were dark. All patients experienced severe symptoms and 36 presented signs and

symptoms of fulminant liver failure. Five deaths occurred in February 2004. None of the patients had any history

or signs of pre-existing chronic liver disease. Laboratory investigations conducted among some of the hospitalized

patients indicated high levels of aminotransferases, Serum bilirubin, and alkaline phosphatase. Two case-patients

who had been tested were negative for IgM antibodies to hepatitis A virus (HAV) and to the hepatitis B virus

surface antigen (HBsAg). Hepatitis E virus infection can cause disease of that kind and may occur as large

community wide outbreaks. The initial negative serological tests for HAV and HBV infection need to be checked

but could suggest HEV as the causal agent. To verify the diagnosis, the investigators collected blood specimens
from case-patients and sent the sera at the Regional Medical Research Centre (Indian Council of Medical

Research), in Bhubaneswar, the state capital of Orissa. Of the 47 serum samples, all were negative for IgM anti-

HAV, HBsAg and antibodies to HCV. However, all serum samples were positive for anti-HEV antibodies in

ELISA, confirming that the investigators were dealing with a hepatitis E outbreak, the first one ever documented

in Orissa.

Given the incubation period for HEV infection (about one month), the exposure probably occurred early in

January. The municipal corporation employees were on a strike during the period of disease detection.

Questions:

1. What are the key steps of the investigation of an outbreak?

2. Can the team determine whether or not they are dealing with an outbreak at this stage? What additional

information would they need?

Table 1: Incidence of acute hepatitis by age and sex, Baripada municipality, Orissa, India, 2004.

Characteristics Cases Population Attack rate

per 1,000
Age 0-4 1 9,488 0.1
5-9 11 13,705 0.8
10-14 37 12,213 3.0
15-44 416 49,689 8.4
45+ 73 20,706 3.5
Sex Male 341 53,449 6.4
Female 197 51,973 3.8
Figure 2: Attack rate of acute hepatitis in the various areas of Baripada municipality, Orissa, India,

February March 2004

Figure 1: Cases of acute hepatitis by week of onset, Baripada, Orissa, India. January- March 2004

3. How can the epidemiological information contained in these figures and this table be described? How can this

information be interpreted?

4. What is the study design to be used in this kind of case? and why?

5. What was the reason for this outbreak?

Case Scenario 5: Mr. Rahul, 17 years old, was brought to Medicine casualty with history of headache, myalgia

and vomiting in the past 2 days. He reached home only 4 days back after a tour along with friends. The day after

he came home, he had mild fever and body ache. He thought it might be due to tedious travel and took rest at

home. But last night his friend phoned him and said that one of their friends was taken to hospital following fever,

vomiting and loss of consciousness. As a health professional what do you think about this episode and how do

we proceed to investigate and manage the situation.

Questions:

1. What might be the disease in question. Define outbreak/epidemic, pandemic.

2. How to detect / recognize an outbreak- warning signs of an impending outbreak.

3. How do we proceed to investigate and manage the situation.

4. What is rumor register and describe the role of media as a source of health information.
Learning Points

a. Define terms: outbreak, epidemic, pandemic.

b. How to detect / recognise an outbreak- warning signs of an impending outbreak - Steps of outbreak

investigation

c. Describing the event in terms of time, place and person and importance of epidemic curve, spot map

and attack rate.

d. Responses at different levels – general and specific measures include reservoir control, breaking the

chain of transmission and protecting the at-risk group.

e. Differentiate between isolation and quarantine.

f. Role of contact tracing in outbreak control.

g. If it is a new disease, gaps will be there, so to fill the gap research activity is required.

Discussion:

Definition of an outbreak/ epidemic: An outbreak or epidemic is defined as the occurrence in a

community or region of cases of an illness clearly more than expected numbers. Usually, an outbreak is

limited to a small focal area, an epidemic covers large geographic area and has more than one focal point.

Pandemic is defined as an epidemic occurring world-wide or over a very wide area crossing international

boundaries and usually affects many people.

Warning signs of an impending outbreak

● Clustering of cases or deaths in time and /or place,

● Unusual increase in cases or deaths,

● Even a single case of measles, AFP, Cholera, plague, dengue, or JE,

● Acute febrile illness of unknown aetiology,

● Occurrence of two or more epidemiologically linked cases of meningitis,

● Shifting age distribution of cases,

● High or sudden increase in vector density,

● Natural disasters. Detecting an outbreak

1. Rumour register: it must be maintained in each public health facility for collecting information related

to infectious diseases. There are key informants in the community like teachers, Anganwadi workers

(AWW), ward members, Self-help Group (SHG), Youth club leaders, etc. They are the eyes and ears of

health services in the community.

2. Media – an important source of health information

3. Review of routine data

4. Through strict vigilance on warning signs of impending outbreak

Steps of outbreak investigation:

1. Verification of the diagnosis: The first and foremost step in outbreak investigation would be to verify

the diagnosis. A clinical examination along with laboratory investigations of a sample of cases may be

sufficient for this, but the epidemiological investigation should not be delayed until laboratory results are

available.

2. Confirmation of existence of an outbreak: For this, Medical Officer should check

● If there is an abnormal increase in the number of cases, or

● See there is clustering of cases, or

● If the cases are epidemiologically linked, or

● If some trigger events have occurred, or

● If many deaths have occurred.

An arbitrary limit of two standard errors from the endemic occurrence is used to define epidemic threshold

for common diseases like influenza. If there is evidence of an outbreak, and if the aetiology, source and

route of transmission are known, specific control measures need to be initiated immediately. If anyone of

the above is unknown, the outbreak must be investigated to identify the specific cause. The Rapid

Response Team (RRT) which was formed during the phase of epidemic preparedness should be alerted

and requested to further investigate the outbreak. At the same time general control measures should be

started.

3. Defining population at risk: before starting investigation, it is necessary to have the attack rates.
4. Rapid search area map and age gender distribution of entire population in the area. This is essential

for calculating for all cases and their characteristics: this is to identify all cases including those who have

not sought medical care and those possibly exposed to the risk. For this, we can use a carefully designed

epidemiological case sheet. The information collected should be relevant to the disease under study. Based

on the information collected from the affected ones, search for more cases and their contacts should be

continued. Laboratory investigations are done with the help of microbiologist. Microbiologist may advise

on what samples are required, mode of collection and transport and also the laboratory to which these are

to be sent. Entomological investigation should also be done if the outbreak warrants it.

5. Data Analysis: Data collected should be analysed to identify common event or experience using the

epidemiological parameters like time, place and person. Time: Epidemic curve can be constructed based

on chronological distribution of dates of onset and number of cases. It may suggest a time relationship

with exposure to a suspected source, whether it is a common source or propagated epidemic, whether it is

of a seasonal or cyclic pattern. Place: A spot map is prepared with cases in relation to possible source of

infection. Clustering may suggest common source of infection. Person: Analyse the data by age, sex,

occupation, and other risk factors. Find out attack rates/ case fatality rates for those exposed and not

exposed. In food borne epidemic, food specific attack rates are calculated.

6. Formulation of hypothesis: on the basis of time, place and person analysis, hypothesis is formulated

to explain the epidemic in terms of possible source, causative agent, possible modes of spread, people at

risk and the environmental factors

7. Testing the hypothesis: If the hypothesis fits with the facts, response measures can be initiated;

otherwise, further analytical investigation in terms of case control studies will need to be carried out. In

the meantime, general control measures are carried out.

8. Evaluation of ecologic factors: This is to prevent further transmission of disease. Ecologic factors

include sanitary status of eating establishments, water and milk supply, break down in water supply,

population movements, atmospheric changes, population dynamics of insects and animal reservoirs.

9. Further investigation of population at risk: To obtain additional information, for e.g. serological

study may reveal clinically in-apparent cases and throw light on the pathogenesis of the condition.
10. Writing the report: This can be an interim report which includes details of the investigation, the

diagnosis and control measures initiated. Once the outbreak is coming under control, we should make

follow up visits to see whether control measures are implemented adequately and also help to collect new

information which was missed in the previous visits. The final report is given within 10 days of the

outbreak being declared to be over. The outbreak is declared over when there are no new cases for a period

of two incubation period since the onset of last case.

Responses to an outbreak

1. General measures is till the specific source and route of transmission is identified. For example, if one

is suspecting a droplet infection outbreak, start a campaign requesting people to follow social distancing,

use of mask and hand hygiene.

2. Specific measures depend on the causative agent. The broad steps are:

● Identification and nullification of the source of outbreak like chlorinating wells,

● Minimising transmission to prevent further exposure: vector control,

● Protection of the host- immunization / chemoprophylaxis,

● Controlling the reservoir include early diagnosis, notification, isolation, treatment, quarantine.

Isolation: Separation of infected persons or animals for the period of communicability from others in such

places and conditions as to prevent or limit the direct or indirect transmission of infectious agent from

those infected to those who are susceptible. Purpose is to protect the community by preventing transfer of

infection from the reservoir to the possible susceptible host.

Quarantine: Limitation of freedom of movement of healthy person or domestic animals exposed to

communicable disease for a period not longer than the longest usual incubation period of the disease to

prevent contact with those not so exposed.

Contact tracing: The process of identifying, assessing and managing people who have been exposed to

a disease to prevent onward transmission. When systematically applied, this will break the chain of

transmission of an infectious disease and is an effective tool in public health. This has to be explained

according to the scenario provided.

Resources:

1. Park’s Textbook of Preventive and social medicine - 25th edition-published by Banarasidas Bhanot-

2019.

2. Medical officer’s manual on Integrated Disease Surveillance Project by National institute of

Communicable Diseases, DGHS, GOI 2006.