INVESTIGATION OF AN

EPIDEMIC / OUTBREAK

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 Overview
Introduction

Incubation Period

Investigation of epidemic

Objectives

Principles

Preparation of field work

Steps of investigation

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INTRODUCTION
Epidemic: Unusual occurrence in a community or region a

disease / health related behaviour / health related event clearly

in excess of expected occurrence
Outbreak term used for a small usually localized epidemic

Keyword in definition- ‘in excess of expected occurrence’

Arbitrary limit from endemic occurrence- two standard error

Ex: Cholera

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 INTRODUCTION
Endemic: Constant presence of a disease/ agent in a geographical

area/ population without importation from outside

Types –

Hyper-endemic-constantly present in high incidence

Holo-endemic- high level of infection beginning early in life.

Ex: Stable malaria

Pandemic: An epidemic usually affecting a large population,

occurring over a wide geographic area.

EX: Influenza pandemic 1918 and 1957

Cholera ElTor- 1962

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 Incubation Period
Time interval between invasion of an infectious agent and

appearance of first sign/symptom of disease

Median incubation period: time required for 50% of cases to occur

following exposure
Factors determining incubation period:

a) Generation time: time between receipt of infection and maximum

infectivity . Ex: mumps

b) Infective dose: Vibrio cholerae, Salmonella

c) Portal of entry
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d) Individual susceptibility
 Incubation Period
Uses

1)Tracing the source of infection and contacts

Ex: in diseases with short incubation period like food poisoning,

dysentery

2) Period of surveillance or quarantine – equal to maximum incubation

period of disease

3) Immunization : prevent clinical illness by human immunoglobulin &

antisera

4) To identify pattern of epidemic

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Prognosis : Ex – Tetanus, Rabies 6
Investigation Of Epidemic
Investigation –an examination for the purpose of finding

out about something

An epidemic occurrence- indicates some shift in existing

balance between agent, host & environment

Epidemiology plays a very important role in investigation

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Objectives
To define magnitude of outbreak or its involvement in

terms of time, place & person

To determine condition and factors responsible for

occurrence of epidemic
To identify cause, source, modes of transmission

To determine measures necessary for control of outbreak

To make recommendations to prevent recurrence

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When To Investigate
Depends on following factors:

 Severity of illness

 Transmissibility

 Unanswered questions

 Ongoing illness/ exposure

 Of public concern

 Availability of control measures

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 Principles of Outbreak Investigation
Be systematic

 Follow the same steps for every type of outbreak

 Write down case definitions

 Ask the same questions to everybody

Stop often to re-assess what you know

Line list and epi curve provide valuable information

Coordinate with partners

Environmental – water supply, sanitary department

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 Although steps of investigation of outbreak are

sequential and to be followed one after the other

there may be overlap between different steps!!!

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Preparation for field work
Can’t be mentioned exactly as first step

Occasionally only public health officials decide to

conduct a field investigation before confirming an

increase in cases
Sometimes after data collection and performing

descriptive epidemiology investigators decide that a field

investigation is required.

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Preparation for field work
Two broad categories

1) Scientific and investigative issues:

a) Scientific knowledge , supplies & equipment ,useful

references like journal articles, questionnaires

b) Laboratory resources

c) Equipment for personal protection

d) Plan of action
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 Preparation for field work
2)Management & Operational issues:

a) Selection of team members and know their roles & responsibilities in field

b) Involvement of other agencies

c) Communication plan

d) Arranging travel, lodging , local transportation

e) Notification to supervisors , health officials of the area to be investigated ;

if not

- They can bring investigation to halt

- Limited to access to information

- Lead to withdrawal of support

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 STEPS OF INVESTIGATION

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1. Confirmation of Existence of Epidemic
When observed frequency is in excess of expected frequency

based on past experience for that population

For diseases under surveillance- health department records

Other sources- hospital records, mortality statistics

Rate/ no of cases is compared with data of previous three

years.
Approach physicians and GP’s in community whether they

have been observing more cases with same symptoms.

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Problems
Reporting increased-

a) because of changes in local reporting procedures

b) Changes in case definition

c) Increased interest because of local or national awareness

d) Misdiagnosis/ laboratory error

Areas with sudden changes in population size- increased

susceptibles

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 Example:

Dr X , medical officer of health received a phone call on May

10th from a working women hostel to inform about 2 cases of

diarrhoea & vomiting with mild dehydration
Total 1000 population.4 messes –A,B,C,D for meals, drinking

water from water cooler, snacks from a canteen.

2/1000 is rough incidence. Daily surveillance system with

district hospital indicated maximum 1 case of GE with

dehydration in a day.
05/29/2024
Since it can be cholera also – it was confirmed as an outbreak18
 2. Verification of Diagnosis and Construct
working Case definition
Necessary because the reporting may be spurious

It should be on spot / as quickly as possible

Not necessary to examine all cases to arrive at a diagnosis!!

Lab investigations wherever necessary but should not delay

epidemiological investigation .Only 20- 30% of cases can be

examined.
Verifying diagnosis helps to seek facts about the disease from

previous experience
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 What confusion occurs
In March 1985 , 15 cases of suspected meningococcal

meningitis ( MM) among children with 8 deaths reported from

Bhusaval in Maharashtra.
This created a huge panic [ simultaneous occurrence of MM

from Delhi]
After proper verification of diagnosis , cases were divided to

different categories.
Only 4 cases were verified as MM!!!!
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 Verification of Diagnosis and Construct
working Case definition
Simultaneous appropriate management of cases also important

Summarize the clinical features using frequency distribution

Helpful in characterizing spectrum , verify diagnosis and

develop case definition.

Helps in developing epidemiological case-sheet and laboratory,

environmental and entomological procedures.

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“Syndromic approach” to common ‘epidemic
prone diseases’

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Working Case Definition
Standard set of criteria for deciding whether an individual

should be classified as having disease of interest

Components:

Clinical criteria: fever > 400 c, > 3 loose stools

Restriction by time ( in past two months), place ( residents of

so and so area) and person ( children < 5 years)
Should not include exposure / risk factor

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 Working Case Definition
Cases divided into 3 categories
a) Confirmed- after laboratory verification
b) Probable- Typical clinical features without lab investigations
c) Possible/ suspect- has fewer of typical clinical features
Investigator tries to ensure that a case definition includes most,

if not all of actual cases but very few or no false positives

Initially sensitive definition and later while testing hypotheses

its made more specific

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Working Case Definition
Ex:

Suspect case- person with 1 episode of vomiting & 2

episode of watery stools in a day
Probable- Suspect case criteria+ no fever, no tenesmus &
no blood in stools
Confirmed- Probable case criteria+ lab demonstration of
organisms
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 3.Defining population at risk
By line-listing and also collecting details and where-about of
cases , we can define population at risk
Required to calculate ‘attack rate’.

Ex: Urgent telephonic calls were made to the various government

dispensaries and private hospitals in the city whether similar
cases of gastroenteritis were seen by them on that day. After
confirming about only 2 cases & since both these cases were
from a single place, “people living in that particular hostel” were
defined as the “population at risk”.
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 4. Rapid search for all cases and their
characteristics
Medical survey: to include all cases including those who have

not sought medical care

Epidemiological case sheet: Information collected are

1) Identifying and demographic information

2) Clinical information- signs & symptoms
Date / time of onset
Duration of illness

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H/O hospitalization/ death 27
 4. Rapid search for all cases and their characteristics
3) Risk factor information- depending on disease
Ex: cholera- all meals, snacks, water source, drinks consumed
between day 1 & day 5 prior to onset of symptom

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Ex: Dr X after investigating the field could identify that

disease would have come from either drinking water from

water coolers , or from food prepared in messes; or from some
snacks / Lassi consumed at the local canteen; or from water
consumed from coolers or some snacks consumed at
workplace. These factors were kept in case sheet.
By now, lab results came as cholera & so history was recorded from

day 1 to day 5 before onset.

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New case search till area is declared free of outbreak- period usually

taken as twice the incubation period of the disease since occurrence

of last case.
 Organize the laboratory

Ex: Small lab with a portable container having gloves, rectal swabs,
Cary –Blair transport medium , vials and PPE. Dr X decided to collect
stool samples, rectal swabs, food samples, water samples and serum

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Contact administrative and engineering authorities

Ex: Dr X contacted PWD authorities and also obtained sanction from

District Magistrate
By now 7 cases were found and also +ve for V.cholerae

Information also collected from who did not suffer from disease

Useful in later part of investigation during comparison between

cases & controls

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 5. Describe the epidemic
Crucial step because
i) Comprehensive characterization of outbreak like trend,
distribution
ii) Infer population at risk
iii) Clue about etiology, source, modes of transmission
iv) To begin control & preventive measures
v) To calculate attack rates
Describing w.r.t time
Histogram to depict time course of epidemic- epidemic curve
/epi curve
Time of onset of illness for each case should be known

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 Epidemic curve
Inferences :

 Shows magnitude of epidemic

 Where you are in the course of epidemic

 For evaluation like how long it took health dept to identify/

are intervention measures working
 Outliers may provide important clues
Early case- source/ exposed earlier/ unrelated
Late case- Long IP, secondary cases, late exposure, unrelated
 Minimum , average & maximum incubation period
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  Shape provide clue about pattern of spread . i.e point vs
intermittent vs propagated
Curve with steep upslope and more gradual down slope –
Point source epidemic

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Curve with plateau instead of peak- continuous common source

Irregularly jagged curve- Intermittent common source

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To identify likely period of exposure:

i) knowing average and minimum IP from fact sheets

ii) Identify the peak of the outbreak or the median case and
count back on the x-axis one average incubation period. Note the
date.
iii) Start at the earliest case of the epidemic and count back the
minimum incubation period, and note this date as well.
iv) two dates will be similar, and represent the probable period
of exposure(not precise, widen the probable period of exposure)

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 Probable
No of cases
exposure time
Median incubation time
(Intervall between first and last disease onset)

2
15 3

10

0
1 2 3 4 5 6 7 8 9 10 11 12 1314 15 16 17 18 19 20 21 22
Time

Probable exposure 50% 1 50%

time Median onset time
 Similarly if time of exposure and onset of illness known

IP can be estimated & disease can be known

 Subtract the time of onset of the earliest cases from the

time of exposure - the minimum IP.

Subtract the time of onset of the median case from the

time of exposure -median IP

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 Probable exposure period
No of cases

maximum incubation time

minimum incubation time

1 3 51 27 3 9
4 5 116 713 8 15
9 10 17 1913 14
11 12 21 15 23 2518 19
16 17 27 2029
21 2231 Time
Probable
exposure
period
 5. Describe the epidemic
Describe w.r.t Place
Given by making spot map of area on which case are plotted.

Uses:
i) Provides geographic extent of problem
ii) Demonstrates patterns that provide etiologic clues
Eg : John Snow’s investigation on cholera in Golden square district
of London in 1854
Can’t be used to compare incidence between different areas
with different population densities
Many spot maps in same investigation:
like place of residence, occupation, recreation, onset of illness
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John Snow’s investigation on cholera in Golden
square district of London

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 Describe w.r.t Person
 Provides a description of who cases are and who is at risk
 Age, sex, occupation, race etc
 Helps in calculation of attack rates

 Ex: By now 7 cases were admitted in district hospital from

same hostel. Information was recorded in case sheet.
 In addition 50 healthy people were also chosen randomly
& information was obtained.

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05/29/2024 44
Ex: 2 cases had onset on 10th May, 3 on 11th and 1 each on 12 and

13th May. There was no case thereafter. The 7 cases were plotted
according to the date of onset of their symptoms. The resultant curve
showed a sharp rise, a sharp peak and an abrupt fall, indicating a
“common vehicle, single exposure (point source)” transmission.
3 different spot maps were made - according to workplace, place of

staying and place of routine eating and drinking, and cases were
plotted as coloured dots on these maps. A clear - cut “clustering” was
seen in all the three maps – in mess No. ‘B’, at workplace No. 1 and in
Living dormitories No. 4 and 5

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6. Developing various tentative hypothesis
Proposition or a tentative theory designed to explain

observed distribution of disease in terms of causal

association of direct nature
May address source/ modes of transmission/ exposure

It should be testable

Possible after summarizing clinico -epidemiological profile

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6. Developing various tentative hypothesis
Can be developed by:

 Knowing about the disease- like reservoir, vehicle, risk factors

 Talking to cases- conversing about possible exposure, sources

 Help from local health department

 From descriptive epidemiology

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 7. Testing of hypothesis
Comparisons between cases & controls using Analytical
epidemiology
Compared in each & every possible hypothesis
Odds ratio calculated & statistical significance seen by Chi-
square test

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 Risk ratio/ relative risk
Method for calculating risk ratio:
RR= Attack rate (risk) in exposed group
Attack rate (risk) in unexposed group
Measures association between exposure & disease

RR=1; Exposure not associated

Greater the difference in attack rates between the exposed and

unexposed groups, the larger the relative risk, and the stronger
the association between exposure and disease
Attack rate= Developed disease among exposed X 100
Population at risk
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 Ex: Table includes data from an investigation of an

outbreak of Salmonella typhimurium gastroenteritis

following a company's holiday banquet in December
Approximately 135 persons attended the party, and of 116

who were interviewed, 57 (49%) met the case definition.

Food-specific attack rates for those who did and did not

eat each of 5 items served are presented.

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Food items No of persons who ate No of persons who did not eat Relati
ve risk

Ill Not ill Total Attack Ill Not ill Total Attack
rate rate

Beef 53 28 81 65% 4 31 35 11% 5.7

Ravioli 43 35 78 55% 14 24 38 37% 1.5

Cajun sauce 19 11 30 63% 37 48 85 44% 1.5

Mushrooms 32 26 58 55% 24 31 55 44% 1.3

Potatoes 39 41 80 49% 17 17 34 50% 1.0

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Beef, which had the highest attack rate among those who ate it,

the lowest attack rate among those who did not eat it was the
culprit
RR indicates the persons who ate beef were 5.7 times more

likely to become ill .

Method for calculating population attributable risk percent:

( ARP − ARU )

ARP

ARP = Attack rate (risk) in total population

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Describes proportion of illness that could be attributable to an

exposure
In Ex :Population attributable risk percent (49.1 − 11.4) = 76.7%
49.1
Statistical significance testing : by Chi-square test- likelihood of

an association as large on basis of chance alone

In above example the RR-5.7 and p-value - <.001 , so null

hypotheses ( beef not associated ) was rejected and alternative

was accepted

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8. Further search for environmental & other
causative factors
In Ex: after the results pointed out to B mess, conditions there

were tested.
study of hygiene and sanitation of cook house, dining

halls, drinking water storage and handling, health state

of food handlers were evaluated.
noticed that the tap of the water cooler was not functioning and

hence drinking water was drawn manually by mess waiters, by

immersing
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a “jug” into the cooler. 54
  There were total of 9 food handlers in ‘B’ mess & 1 of

the waiters ‘Q’ had not reported for duty because of “upset
stomach” from 10th may to 13th May.
Clinical exam of all these food handlers was undertaken

and rectal swabs of all 9 were dispatched to the laboratory

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 9. Final lab proof of cause & effect
relationship
Difficult but gives final proof

Ex:

Water samples from water cooler showed very high coliform

count of 180 per 100 ml but no E coli.
Rectal swab of the food handler ‘Q’ grew V cholerae 01 Ogawa,
i.e. the same biotype and serotype as was isolated from the 7 cases.

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 10. Implement control & preventive
measures
Most primary goal

Begin as early as possible

Launched before investigation if appropriate measures known

Directed against one more segments in chain of transmission

Agent Modes of Portal of Host
Source transmission entry

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Measures directed towards source of infection:

 Treatment of cases & carriers

i) Reduces communicability of disease

ii) Cut short duration of illness
iii) Prevents development of secondary cases

Types : Individual treatment

Mass treatment - all in community are treated whether
they have disease or not Ex: Trachoma, filariasis
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Measures directed towards source of infection:
 Isolation

Separation for period of communicability of infected persons/

animals from others in such places and such conditions , so as to
prevent/ limit transmission to those who are susceptible.
Types
i) Standard

ii) Strict: In disease that spread by air

iii) Protective

iv) High security : Unusually highly contagious

Ex: Ebola virus, small pox

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 Problems in isolation

i) Large component of sub-clinical infection & carriers

Ex: Polio, Hepatitis A , Typhoid fever
ii) Highly infectious before it is diagnosed Ex: mumps
iii) Cases are reported after disease spread widely
Ex : Food poisoning

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Measures directed towards source of infection:

 Quarantine : Limitation of freedom of movement of such well

persons/domestic animals exposed to communicable disease for a
period of time not longer than longest incubation period.
 Types :

i) Absolute
ii)Modified – selective partial limitation of freedom of movement
Ex: exclusion of children from school during treatment for
diphtheria, scabies

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iii) Segregation : Separation for special consideration, control of

observation of some part of a group of persons from others to

facilitate control .
Ex: removal of susceptible children to homes of immune persons
Measures directed to modes of transmission:
 Protection of water supply
 Food hygiene
 Vector control
 Proper waste management
 Various disinfection procedures

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Measures directed to portal of entry:

 Use of bed-nets

 Masks & gloves

 Insect repellants
Measures directed to susceptible host:

 Active & Passive immunization

 Chemoprophylaxis

 Personal protective measures

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 11. Initiate & maintain surveillance
Continuous scrutiny of all aspects of occurrence & spread of

disease that are pertinent to effective control

Purpose:

i) To monitor whether the control measures are working

ii) To know whether the outbreak has spread outside its original
area

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 11. Initiate & maintain surveillance

Ex:
Super-chlorination, Pipelines were repaired

Food handler Q was removed from duty for 5 days &

treated with oral tetracycline

All other workers – a dose of oral doxycycline

Damaged tap of B mess repaired

Daily surveillance system launched in hostel

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 12. Communicate findings
Final step – to summarize and prepare a report of investigation
An oral briefing- to local authorities who implement control
measures
A written report
Uses:
 Blue print for action

 Serves as a record of performance

 Document for legal issues

 Reference for similar situation in future

 Knowledge base of epidemiology & public health

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 Conclusion
Epidemiological investigations are crucial for finding the

source, modes of transmission and also control the

outbreak with specific measures.
Follow the steps

Implementation of control measures is primary goal of

any investigation.

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IDSP
Integrated disease surveillance project

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Team under the Integrated Disease
Surveillance Programme (IDSP), typically
include:
• District Surveillance Officers (DSOs)
• Epidemiologists
• Microbiologists
• Entomologists
• Laboratory technicians
• Health workers
• Medical officers
• Community health officers
• Paramedical staff

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05/29/2024 72
 References
1. Park K. Park’s textbook of preventive and social medicine. 23nd ed.
Jabalpur M/s Banarasidas Bhanot Publishers 2015; p.131-133
2. Col Rajvir Bhalwar Public Health and Preventive Medicine – “The
RED BOOK” Diamond Jubilee Edition New light publishers 2008;p
184-196
3. Leon Gordis. Epidemiology. 5th ed. Elsevier Saunders 2014; p 22-37
4. P.V.Sathe & P.P Doke. Epidemiology & Management for Health
care. 4th ed. Mumbai, Vora Medical Publications 2014; p 34-45
5. CDC. Principles of epidemiology in public health practice . 3rd ed.
6. Oct 2006. http://www.cdc.gov/ophss/csels/dsepd/ss1978/
7. Wallace R. Public health & preventive medicine. 15th ed. The
Mcgraw Hill Companies. 2008; p 14-17

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 THANK YOU

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