Why to investigate an outbreak
Stop the epidemic
Characterize a public health problem
Identify preventable risk factors
Prevent new episodes
Provide new research insights into
disease
Train health department staff in
methods of public health
investigations and emergency
response
Evaluate the system
Steps in Outbreak Investigation
Define the outbreak and validate the
existence of an outbreak
Define Case and Examine the
distribution of cases
Look for combinations (interactions) of
relevant variables (descriptive
epidemiology)
Develop hypotheses
Test hypotheses
Recommend control and preventive
measures
Prepare a written report
Communicate findings
These steps may occur simultaneously
or be repeated as new information is
received.
Who must report
Confidentiality of report
Define the outbreak and validate
the existence of an outbreak
Define the numerator (cases)
(1) Clinical features: is the disease
known?
(2) What are its serologic or cultural
aspects?
Appropriate test, time , method and
handling
(3) Are the causes partially
understood?
b. Define the denominator: What
is the population at risk of developing
disease?
c. Determine whether the observed
number of cases clearly exceeds the
expected number
d. Calculate the attack rates
Verifying the existence of a true
outbreak is critical to proceeding with
an investigation. Confirmation of the
diagnosis with a laboratory is
important, especially if the pathogen is
new or unusual.
An attack rate is defined as:
No of people at risk in whom certain
illness develops
Total No of people at risk
In epidemiology, an attack rate is
the cumulative
incidence of infection in a group of
people observed over a period of time
during an epidemic
It is measured from the beginning of
an outbreak to the end of
the outbreak.
The attack rate (or the incidence rate)
is useful for comparing the risk of
disease in groups with different
exposures
2. Examine the distribution of
cases
Examine the distribution of cases by
the following:
person
time
 Place} Look for timeplace
interactions
Frequency tables, mapping,
epidemiological curve
Create line listing
Person
Who was infected?
What do the cases have in
common?
Place
Where were they infected?
May be useful to draw a map
Time
When were they infected?
Create an epidemic curve
Develop a Case definition
Incubation period for E. coli O157:H7
ranges from 3-8 days with a median of
3-4 days.
The infection often causes severe
bloody diarrhea and abdominal cramps,
but can also cause a non-bloody
diarrhea or result in no symptoms.
In some persons, particularly children
under 5 years of age and the elderly,
infection can be complicated by
hemolytic uremic syndrome (occurs in
about 2-7% of infections)
Case Definition
Outbreak investigation definition:
1. diarrhea (>3 loose bowel
movements a day) and/or abdominal
cramps
2. resident of Michigan
3. onset of symptoms between June 15 and
July 15
4. stool culture yielding E. coli O157:H7
with the outbreak strain PFGE pattern.
What could account for the
increase in cases?
Real increase
Increase in population size
Changes in population
characteristics
Random variation
Outbreak
Artificial increase
New testing protocol
Contamination of samples
Changes in reporting
procedures
3. Look for combinations
(interactions) of relevant
variables
Look for combinations
(interactions) of relevant
variables
4. Develop hypotheses
Develop hypotheses based on the
following
literature reviews of previous
outbreaks
Existing knowledge (if any) of
the disease
interviews of several
case-patients
correlation to diseases of
known etiology
Findings from investigation of
the outbreak
5. Test hypotheses
Conduct an analytic study to
test hypotheses
Retrospective cohort study
 Case-control study communicate progress and
Refine hypotheses and collect findings
additional data that may be
needed Communicate findings to
6. Recommend control those involved in policy
measures development and
implementation and to the
Control of current outbreak
Prevention of future similar
outbreaks
Implement and evaluate control
measures
Prevent further exposure and
future outbreaks by
eliminating or treating the
source
Work with regulators, industry,
and health educators to
institute measures
Create mechanism to evaluate public
both short- and long-term
success
7. Prepare a written report of the
investigation and the findings
Summarize investigation, You are called upon to carry out
make recommendations, and an outbreak of vomiting and
disseminate report to all stomach cramps following a
participants reception held by the High
Commission Organization. The
following table derives from this
investigation.

8. Communicate findings

Identify a single member of

the investigation team to
interact with media and
Conclusions
The steps listed for an outbreak
investigation comprise a brief
introduction and rough guide.
Only by conducting investigations
repeatedly over an entire career
will public health professionals
truly learn the methods of
outbreak investigations.