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Epidemiologic Investigation and

Management of Outbreak/Epidemic

Learning objectives
At the end of this module, participants will be able to:

• Define common terms related to disease occurrence

• Identify Epidemic and types of Epidemic

• Describe the steps in the investigation of an outbreak/

epidemic

• Describe the different approaches of outbreak/epidemic

management

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Contents
1. Introduction

– Common terms related to disease occurrence

– Epidemic and types of Epidemic

2. Investigation of an outbreak/epidemic

3. Principles of outbreak/epidemic management

1. Introduction
• Disease occur in a community at different level at
particular point in time
– Predictable level called expected level
• Endemic
• Holo/hyper/meso/hypoendemic
– Excess of what is expected
• Epidemic, Outbreak, Pandemic, Cluster
– Irregular and occasional occurrence
• Sporadic

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Introduction…
• Epidemic:- occurrence of disease or health related
condition in excess of the usual frequency in a given
area or among a specified group of people over a
particular period of time.

Introduction…
Note
1. A disease may be endemic in a population at any
frequency level, provided that it occurs with
predictable regularity.

2. Epidemic can refer to any disease and health

related conditions.

3. The minimum number of cases that fulfils the

criteria for epidemic is not specific and the
threshold may vary
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Introduction…
4. Knowledge of expected number is crucial to
label occurrence of a particular event as
epidemic

5. Expected level varies for different diseases and

different geographic locations

Introduction…
• Outbreak:- epidemic of shorter duration covering a
limited area.
E.g. Outbreak of gastroenteritis after sharing a common meal
at an event

• Pandemic:- an epidemic involving several countries

or continents affecting a large number of people.

E.g. - influenza pandemic

- HIV pandemic
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Introduction…
• Cluster:- unusual aggregation of health events in a
given area over a particular period.
⇒emphasis is on aggregation of cases in a certain locality
than the actual number of cases.

E.g. 3-4 cases of certain illness that occur in certain kebele

while no cases occur in all other kebeles of certain district

Introduction…
• Sporadic:- a disease that is normally absent from a
population but which can occur in that population,
although rarely and without predictable regularity.

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Introduction…
Examples of disease occurrence in Ethiopia:
1. Endemic: malaria, schistosomiasis, chronic hepatitis,
trachoma, scabies, malnutrition, amoebiasis,
tuberculosis and typhus.

2. Epidemic: Cholera, yellow fever and meningococal

meningitis
3. Sporadic: Colonic cancer, Parkinson’s disease, etc.

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Introduction…
• Types of Epidemics
– Common source
• Point source:- e.g. food borne outbreak of acute Gastro
enteritis in attendants of a wedding feast

• Continuous/intermittent:- e.g. water borne outbreak that

spread through contaminated community water supply

– Propagated/progressive:- e.g. outbreak of measles,

yellow fever, malaria
– Mixed:- e.g. most food borne outbreaks
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2. Outbreak investigation
• Outbreak investigation is a method for identifying
and evaluating people who have been exposed to an
unusual occurrence of disease/other health problems.

• It’s an important component of Epidemiology and

Public Health;
– which through systematic way helps in identifying the
source of ongoing outbreaks and preventing additional
cases.

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Outbreak investigation…
– Challenges in outbreak investigation
1. Urgency to find out the source and prevent additional
cases and substantial pressure to conclude rapidly
particularly when outbreak is ongoing;
– may lead to hasty decisions regarding source and
negative consequence on control measures

2. Involvement of many agencies and investigation at

many levels;
– poses threat to undertake coordinated work
3. Limited number of cases available for the study
– Limits statistical power of the investigation
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Outbreak investigation…
• How are outbreaks recognized?
– Possible outbreaks of Ds come to the attention of public
health officials in various ways:

a) Review of routinely collected surveillance data can detect

outbreaks of known diseases

b) Observant health professionals might 1st notice unusual

disease or unusual number of cases of a disease and alert
public health officials

c) A patient/someone close to patient 1st suspects a problem

d) Local newspaper/television news 15

Outbreak investigation…
• Why are outbreaks investigated?
– The most compelling reason is that exposure to the
source(s) of infection may be continuing
⇒Investigation provides helpful information:

To take immediate action (i.e. by identifying and
eliminating the source of infection we can prevent
additional cases)

– Result of investigation may lead to recommendation/

strategies for preventing similar future outbreaks
⇒Helps in improving long term disease prevention activities
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Outbreak investigation…
– Other reasons include:
• To describe new diseases and learn more about
known diseases

• To evaluate existing prevention strategies

e.g. vaccines

• To address public concern about outbreak

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Outbreak investigation…
• When should outbreaks be investigated?
– For some communicable Ds, a single suspected case
might suffice the start of the process of investigation
⇒Need immediate investigation and immediate response
– For some other Ds,

when a certain threshold is passed or

when un usual increase in the number of deaths due
to certain cause is noticed during analysis of
surveillance data or

when cluster of deaths due to unknown cause is seen
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Outbreak investigation…
• Activities in Outbreak investigation

– There is no rigid step to follow during investigation of an

outbreak

– Several activities could be accomplished simultaneously

– The steps to follow are set by individual investigator

depending on the suspected cause of the outbreak

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Outbreak investigation…
– The activities include:

1. Verify that there is an epidemic/outbreak

2. Prepare to conduct an investigation
3. Construct a suspected case definition
4. Collect laboratory specimens and obtain laboratory
results
5. Search and record additional cases while managing
the already identified cases

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Outbreak investigation…
– Activities…

6. Describe the epidemic/outbreak with respect to time,

person and place
7. Formulate hypothesis about the cause of the
epidemic/outbreak and test them
8. Reach at final decision based on all available
evidences
9. Intervene(take action)
10. Report and disseminate findings

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Outbreak investigation…
1. Verify that there is epidemic/ outbreak
– Reports about presence of epidemic are not always
correct
⇒ Important for considering resource that would be
expended for artifuactual rise in number of cases/
deaths
a) Verifying the diagnosis in the index case/s
b) Compare current occurrence with the expected
occurrence considering seasonal variations
c) Rule out artifuactual changes in the occurrence of
diseases
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Outbreak investigation…
– The following three things should be considered to
declare epidemic in case of incomplete data:

• If there is a risk for wider transmission when left

without intervention
e.g. Viral hemorrhagic fever vs neonatal tetanus

• Severity of the disease

e.g. Viral encephalitis vs mild viral skin rash

• Availability of resources to effect a plausible

intervention
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Outbreak investigation…
2. Prepare to conduct an investigation
a) Search and gather scientific information necessary for
the outbreak investigation
– No single investigator is fully knowledgeable about all
diseases and health problems which need Investn and
appropriate management of their outbreaks.

⇒Investigator should always update him/herself with

necessary scientific knowledge both on:

– Nature of disease to be investigated

– Scientifically proven/sound methods of
investigating and management of the epidemic24

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Outbreak investigation…
b) Make important communications

– Identify and communicate people (units of government

organizations) responsible for investigating and/or
managing epidemics

– Using the already available data and discussing with

responsible persons;

Decide where to undertake the investigation taking
the most affected geographical location as a starting
place for outbreak investigation

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Outbreak investigation…
c) Establish an outbreak investigation and management
team
– For smooth execution of outbreak investigation and
management establish team with clearly defined roles.

– If there is epidemic preparedness, involve already

identified team members that will take part in epidemic
investigation and management
• Team members should be well aware of their specific
roles in the process
• Team should plan and decide how communication among
the team members will go during investigation
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Outbreak investigation…
d) Develop data collection tool for the outbreak investign
– The investigation team should develop collection tool
with the following variables regardless of disease
under investigation
• Identifying information: Name, address, etc
• Socio-demographic variables: age, sex, occupation, etc
• Clinical and lab infon: Sx, signs, date of onset, lab test
result
• Risk factor infon: exposure to suspected causes, e.g.
contact with people with similar illness, travel history,
immunization status…
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Outbreak investigation…
e) Make administrative arrangements

– One of the major factors affecting success of outbreak

investigations
– Beginning from the start of the epidemic investigation
investigators should plan for:
• Adequate transportation, personnel, equipment and
logistic supplies
– Effort should be made to obtain essential materials in
advance of beginning of actual investigation activities
e.g. Lab materials - serologic kits, etc
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Outbreak investigation…
3. Construct a suspected case definition
– Suspected case definition is definition of a Ds used at
initial stage of outbreak investigation

– It includes clinical (general description of the type of Ds)

and epidemiological criteria (description of a disease by
time, person and place)

– It lacks specificity, and identified cases are also called

suspected cases.

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Outbreak investigation…
4. Collect laboratory specimens and obtain laboratory
results
– Laboratory results are mandatory for most epidemics of
infectious diseases for:

Confirming diagnosis in the individual patient

understanding the cause of the epidemic

– Laboratory investigations usually include:

Microscopic demonstration or isolation by culture of
the agent

Serologic studies (done two times, 4 weeks apart)
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Outbreak investigation…
– Based on additional lab results, the cases who fit
suspected case definition can be classified as:
• Confirmed/definite: A cases with lab confirmation
• Probable: A cases with typical clinical features of the
disease without lab confirmation
• Possible: A cases presented with fewer of the typical
clinical features
– laboratory tests may include environmental investigations:
• food sanitation
• suspected breeding sites
• animal reservoirs
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Outbreak investigation…
5. Search and record additional cases while managing
the already identified cases
– This is done by:
a) Passive surveillance (stimulated)
– Searching similar cases in the registers of health facilities
where cases have been reported

b) Active surveillance
– Sending out letter describing situation & asking for reports
– Alerting public directly to see physician if they have Sx
compatible with diseases in question
– Asking case-patients if they know any one else with same
condition
– Conducting active case finding mission 32

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Outbreak investigation…

– Meanwhile:

Cases of the disease that are already identified
should get the appropriate treatment.

Necessary precautions for preventing disease

transmissions in health facilities should be in order.

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Outbreak investigation…
6. Describe the epidemic with respect to time, person
and place

– Purpose:
• To get a clue about the general features of the
epidemic:
– where are most cases of the epidemic seen
– where is epidemic spreading to
– what the source of the epidemic is
– who the high risk groups are, etc
so that early and timely measures can be started.
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Outbreak investigation…
a) Characterize epidemic by time: epidemic curve

– Epidemic curve is a graph (commonly histogram) showing

the distribution of cases plotted over time
• Date of onset of cases: depicted on x-axis
• Number of cases corresponding to each date of onset:
shown on y-axis
– Several information can be obtained from epidemic curve
• Type of epidemics
• Probable date of exposure
• Probable etiologic agent
• Timelines of case detection
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Outbreak investigation…
• Type of epidemics
– Point source
• Rapid rise and fall (log-normal distribution) except for
diseases with long IP (e.g. Hepatitis A)
• The curve starts and ends within a single incubation
period

– Continuous/intermittent common source

• Epidemic curve will have no clear peak (wider or
irregular) and has more than one IP

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Outbreak investigation…

Epidemic curve for point source epidemic

c a = minimum IP
b = duration of outbreak
Number of

c = mode of IP
a + b = maximum IP
cases

a b

Date of
Exposure onset

First case Last case 37

Outbreak investigation…

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Outbreak investigation…

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Outbreak investigation…

– Progressive/propagated epidemic:

• Initial slow rise

• Succession of several peaks
• Prolonged duration ( more than 1 IP)
• Sharp fall

In reality, few propagated outbreaks provide classic pattern.

Epidemics of highly infectious diseases with short IP can
create rapidly rising and failing curve (e.g. influenza).

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Outbreak investigation…

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Outbreak investigation…
• Probable date of exposure (from point source curve)
– The time till date of mode of epidemic curve is taken
as average IP of etiologic agent
– Date of exposure = date of the mode – average IP

• Probable etiologic agent (from point source curve)

– Average IP = date of mode – date of exposure
⇒ By determining the average IP, it is possible to guess
infectious agent because most infectious agents have
relatively unique duration of IP.

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Outbreak investigation…
Estimating date of exposure Peak

10
One incubation period
9 Rubella = 18 days
8
7
Probable time of

6
Cases

5
4
exposure

3
2
1
0
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29

Days
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Outbreak investigation…
Estimating date of exposure
10 Maximum incubation
9 21 days
8
7
Probable time of

6
Cases

5
exposure

4
3
2 Minimum incubation
1 14 days
0
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29

Days 44

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Outbreak investigation…
• Timelines of case detection, investigation and
response

– In addition to date of onset of each case, the x-axis

can also be made to show the following dates:
• Dates of Index cases detection
• Date of report to the investigator
• Date when investigation was began
• Date when response was began

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Outbreak investigation…

– Using distance from the onset of illness in the index

case(s), one can determine:
• Level of community awareness about disease
under investigation

• The timeliness of report from health institutions

• The timeliness of response from the investigator(s)

• The timeliness of measures taken, etc

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Outbreak investigation…
b) Characterize the outbreak by place: Spot map

– Spot map is epidemiologic tool to describe epidemic

by place
– It shows only number of cases in their respective
place of residence
– It doesn’t consider population density difference of
each subarea
⇒supply it with place specific attack rates particularly if
there is perceived variation in population density

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Outbreak investigation…
• Application of Spot map
– Shows cluster of cases
– Shows relation of clusters with presumed sources of
infection
– Helps to distinguish between common source and
propagated epidemic when difficult to identify them
by the epidemic curve

Propagated epidemic: geographic spread with
successive generation of cases

Common source epidemic: cases tend to aggregate
in certain place
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Outbreak investigation…
Spot map showing distribution of cases by place

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Outbreak investigation…
Spot map showing distribution of cases by place

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Outbreak investigation…
c) Characterize the outbreak by person: person specific
attack rates
– Identifying personal variables that could be related with
the cause of epidemics gives valuable clues about:

the epidemic

the high risk groups
– Identifying high risk groups makes issuing interventions
feasible in addition to unraveling helpful clues as to the
cause of the epidemic.
E.g. some of the interventions are not plenty enough to give
to every affected population (e.g. vaccination)
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Outbreak investigation…
– Some of personal characteristics include (depending
on type of disease):

• Age, sex, occupation,

• Pertinent travel history, Residence (urban, rural)
• Immunization status, inpatient/outpatient status,
• Outcome of case (survived/died)
• Lab results

rate calculated from these variables is called

person specific attack rate (e.g. sex specific AR)

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Outbreak investigation…
7. Formulate and test hypothesis about cause of the
epidemic

– Data obtained from descriptive epidemiology (step 6)

is used to formulate hypothesis about the cause of
epidemic

– Formulated hypothesis can be tested by

• The attack rate method
• The case-control method

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Outbreak investigation…
– Attack rate method: two groups (exposed and
unexposed) are compared.

• Attack rate= # new cases during outbreak * 100

Population at risk at the beginning

• The greater the difference in the attack rate between

the two groups, the stronger the evidence that
particular exposure is the cause of the disease

• Concentrate on both groups to avoid bias

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Outbreak investigation…
Attack rate method
Number of people Number of people who
who ate specified item did not eat specified item
Attack Attack Relative
Food Ill Well Total Ill Well Total
Rate % Rate % Risk
Baked Ham 29 17 46 63 17 12 29 59 1.07
Mashed potatoes 23 14 37 62 23 14 37 62 1.00
Spinach 26 17 43 60 20 12 32 62 0.97
Cabbage Salad 18 10 28 64 28 19 47 60 1.07
Milk 2 2 4 50 44 27 71 62 0.81
Ice Cream (Van) 43 11 54 80 3 18 21 14 5.71
Fruit salad 4 2 6 67 42 27 69 61 1.10
Ice Cream (Choc) 25 22 47 53 20 7 27 74 0.72

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Outbreak investigation…

– Case-control method: two groups (cases and non cases)

are compared.
• The greater the difference in proportion of cases exposed
and non-cases exposed, the stronger the implication of
association between exposure and disease
– In both methods of analysis:
• test of statistical significance and
• confirmation by isolation of etiologic agents from
remnants of the sources or any other evidence is
mandatory

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Outbreak investigation…
Food consumption by cases and controls, outbreak of salmonellosis,
Jura, spring 1997
Foods nr (%) of cases nr (%) of controls OR
have eaten have eaten matched CI 95%
(n=42) (n=42)

Pâtés 11 (26) 17 (40) 0,5 0,2 - 1,3

Sausages 24 (57) 28 (67) 0,7 0,3 - 1,6
Beef 32 (78) 33 (79) 1 0,3 - 3,5
Pork 23 (59) 29 (76) 0,5 0,2 - 1,5
Veal 22 (54) 19 (46) 1,4 0,6 - 3,4
Chicken 30 (71) 34 (81) 0,6 0,2 - 1,7
Munster 4 (10) 1 (2) 4,0 0,5 - 35.8
Bleu de Gex 12 (35) 10 (24) 3,0 0,6 - 14,9
Comté 36 (86) 37 (88) 0,8 0,3 - 2,7
Morbier 33 (83) 23 (55) 6,5 1,4 - 28,8

Outbreak investigation…
8. Reach at a final decision based on all the available
evidences
• This step of investigation should come up with:
– Etiologic agents
– Mode of transmission
– Exposure that cause the disease

Hypothesis testing (as one major evidence) and all other

evidences (lab findings, descriptive epidemiology and
other scientific facts) are used to reach at a decision.

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3. Principles of Epidemic management

3.1 Activities in epidemic management
A. Epidemic preparedness and response
Objective:
• To anticipate/predict the occurrence of epidemics
• To detect epidemics early
• To establish rapid response through guidelines/
trained staff/supplies and in place before epidemic
• To have effective response with appropriate control
method, adequate resources and logistics

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Principles of Epidemic Management…

Components:
a) Establish epidemic preparedness and response
committee
• The key to do this is to establish co-ordination
between all players at national, zonal, district and
kebele levels based on availability of technical staffs:
– Physicians, epidemiologists, microbiologists, public
HO, health educators, Env’tal health workers,
authorities and community representatives.
– This team can then co-ordinate all activities
– It must function on a continuous basis, and meet
periodically even when no epidemics are present.
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Principles of Epidemic Management…

• The points that should be considered during

establishment:
• Members of the committee may vary as per the level
(national to kebele) and mainly includes:
– technical staffs, political leaders, community
representatives, other gov’tal and NGO agencies

• Tasks of the committee should be classified into before,

during and after the occurrence of epidemics

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Principles of Epidemic Management…

– Before epidemics the committee members should:

• Set priorities
• Write epidemic preparedness and response plan
• Define prevention and control strategies
• Ensure that surveillance system can detect epidemic
occurrence
• Assign specific responsibilities for surveillance,
preparedness and response
• Identify and mobilize resources

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Principles of Epidemic Management…

– During epidemics the committee members should:

• Implement plan (verification, investigation and
management of epidemics)
• Rapid and co-ordinate response
• Implement prevention and control strategies
• Monitor and evaluate prevention and control strategies
• Identify, mobilize and utilize available resources
• Reporting

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Principles of Epidemic Management…

– After the epidemics the committee members should:

• Evaluate the preparedness and response
• Review and update the plan
• Modify prevention and control strategies
• Identify and mobilize the resources
• Anticipate new epidemics
• Strengthen surveillance

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Principles of Epidemic Management…

b) Setting priority
• Before setting priority, answer the following based on
literature review, reports, health institution records,…
– Major epidemic prone diseases?
– Risk of epidemics?
• Time since last outbreak: example one may
suspect meningitis outbreak every 2 years
• Frequency of previous outbreaks and recent Ds
trends

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Principles of Epidemic Management…

– Likely impact of outbreak?

• Potential number of cases
• Potential deaths and disabilities
• Likelihood of spread
• Economical and social impacts
– Effective and affordable control measures available?
– Are there adequate resources (human power, drug
supply, money…)?

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Principles of Epidemic Management…

c) Formulate epidemic preparedness plan

– The plan should include:
• List of the priority diseases
• Defined surveillance, preparedness and response
measures to be implemented
• Identified responsibilities (who does what?)
• Identified co-ordination mechanisms (leadership)
• Specified resources available for preparedness and
response (budget)
• Decided list of activities, resources or supplies
• Time framework
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Principles of Epidemic Management…

d) Implement/strengthen surveillance
• Successful epidemic response depends on effective
surveillance system
⇒It is necessary to keep population at special risk
under surveillance during acute phase and then
community after epidemics is controlled.
• Surveillance should keep all links of disease chain
under close scrutiny

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Principles of Epidemic Management…

Sources of information:
• Initial: notification of illness by medical staff,
community health workers, employers of labor,
school teachers, heads of families
• 2nd: Certification of deaths by medical authorities
• 3rd: Data from others sources (e.g. community
members)
– Reporting may be inadequate and active
surveillance must be there while the threat
continues

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Principles of Epidemic Management…

B. Respond rapidly and effectively to epidemics

– Aim: to contain epidemic and to reduce morbidity and
mortality
– It depends on epidemic preparedness and response
activities:
• Early and regular team/committee meeting
• Early assessment of the potential scale of epidemic
• Co-ordinated investigation and implementation of
control measures
• Providing public information whenever important using
health education and media strategy
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Principles of Epidemic Management…

3.2 Epidemic control measures
1) Aim of control measures
– Central to any outbreak investigation is the timely
implementation of appropriate control measures to
minimize further illness and death
– The aim of all control measures is to act at the weak link(s)
in the chains of infection (or any exposure outcome chain)
so as to prevent additional cases of the illness
– However, the type of control measures which would be
taken is dependent on the type of the specific diseases
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Principles of Epidemic Management…

2) Timing of control measures

– Detail epidemiologic outbreak investigation and testing of
environmental specimens may delay prevention of further
exposure to a suspected source of the outbreak.

– Therefore, intervention must start as soon as minimum

adequate information about outbreak is gathered.

– Recall of a food product, the closing of a restaurant or

similar interventions can have substantial negative effects.

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Principles of Epidemic Management…

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Principles of Epidemic Management…

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Principles of Epidemic Management…

3) General classes of interventions

– Control measures for every of infectious diseases of public

health importance are different and relatively peculiar but
most of intervention measures can be grouped into three:
• Measures directed against reservoir

• Measures that interrupt the transmission of organisms

• Measures that reduce host susceptibility

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Principles of Epidemic Management…

a) Measures directed against reservoir

– Domestic animals as reservoir
• immunization, testing of herds, destruction of infected
animals (e.g. Brucellosis, Bovine TB)
– Wild animals as reservoir
• post-exposure prophylaxis (e.g. Rabies)
– Humans as reservoir
• removal of focus of infection (e.g. cholecystectomy for
typhoid carriers), treatment, isolation for the period of
communicability
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Principles of Epidemic Management…

b) Measures that interrupt transmission of organisms

– Transmission by ingestion
• Purification of water, peusteralization of milk, Inspection
of food and drinking establishments, improve housing
conditions,
– Transmission of respiratory infections
• Chemical disinfection of air, use of UV light, improving
ventilation patterns
– Transmission that involves intermediate host
• Avoiding intermediate hosts (e.g. snails from irrigation
farms to control Schistosomiasis)
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Principles of Epidemic Management…

c) Measures that reduce host susceptibility

– Active immunization, e.g. EPI

– Passive immunization, e.g. Rabies, tetanus

– Chemoprophylaxis, e.g. TB, Malaria

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Principles of Epidemic Management…

3.3 Report and disseminate findings
– At the end of epidemic investigation, prepare a
comprehensive report and submit to the appropriate/
concerned bodies
– Report should discuss in detail:
• Factors leading to the epidemic
• Evaluation of measures used for the control of epidemic
• Recommendation for the prevention of similar episodes
in the future
– Disseminate findings through mass media, channels
directed at health workers, and professional journals.
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Summary
• In general, epidemiologic outbreak investigation and
management involves the under listed activities:
1. Verifying that there is an epidemic/outbreak

2. Preparing to conduct an investigation

3. Constructing a suspected case definition

4. Collecting laboratory specimens and obtaining laboratory
results
5. Searching and recording additional cases while managing
the already identified cases

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Summary…

6. Describing the epidemic/outbreak with respect to time,

person and place
7. Formulating and testing hypothesis about the cause of the
epidemic/outbreak
8. Reaching at final decision based on all available evidences

9. Intervening (taking action)

10. Reporting and disseminating the findings

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Reading assignment
1. Monitoring and evaluation of Epidemic
Investigation and management

2. Investigation and Management of Epidemic

prone diseases in Ethiopia

2. Investigation and Management of outbreak in

special settings
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In the investigation of an ongoing outbreak:

*Working quickly is essential!

* Getting the right answer is essential too!!

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