Sumit Karn

link2sumit@gmail.com 10 April 2011

synopsis
Introduction: Epidemiology is Outbreak - - Definition, Detection Investigation - - Steps Examples

role of epidemiology in public health

Surveillance Outbreak Investigation Epidemiological Study Evaluation of Public Health Measures

what is an outbreak???
A situation when diseases, health related behaviour or health events occur at a greater frequency than normally expected (excess of normal expectancy) in a specified period and place

excess of normal expectancy

More than
5-Yr median or Average number + 2 SD of previous 5 year or Average number of previous few weeks or months

2 cases with epidemiologic linkage in short time 1 cases of a new emerging disease

outbreak investigation provides..

Opportunity to discover new etiological agents Understand factors that promote the spread of diseases Identify the weaknesses of existing prevention and health programmes

Specific objectives Identify:

Causal agent Transmission way Source Carrier Population at risk Exposition causing disease (risk factors)

investigate an outbreak why

Stop/control the epidemic and prevent new episodes Opportunity to learn (research opportunity) Evaluate the surveillance system Put in place a surveillance system Learn to teach (training) Public, political, or legal concerns

outbreak detection & prevention and control

usual sequence of events

outbreak detection & prevention and controlcontd..

ideal sequence of events

prevention and controlcontd..

Relative Priority: Investigation and Control Efforts During an Outbreak
Source/Mode of transmission Known Known Causative agent Unknown I+ C +++ I +++ C +++ Unknown I +++ C+ I +++ C+

I Investigation, C- Control +++ - highest priority + - lowest priority Source: Goodman RA, Buehler JW, Koplan JP. The epidemiologic field investigation: science and judgment in public health practice. Am J Epidemiol 1990;132:916.

detecting an outbreak
Sources of outbreak news
Health care providers and other health personnels Laboratory Official disease notification systems Media: Newspaper, TV, Internet Surveillance data that are collected and analyzed timely Village health volunteers and other local people

surveillance data

Reported severe diarrhea cases in Khonkaen, Thailand January 1995 - July 1999

media news about the outbreak

One of the main source of information about outbreak

Compelling to wide population

investigation committee
Multidisciplinary Principle investigator/person in-charge Define tasks Team comprises of:
Field epidemiologist Laboratory technicians Specialist in particular areas (veterinarian, sociologists, entomologist) Public health administrators Public relation in-charge (in case of panic situation)

before implementing an investigation.(preparation)

Assessing the existence of the outbreak Gathering preliminary information
Available data Consult experts Documentation

Ensuring that clinical specimens and suspected materials are collected Inform the concerned and get authorization and adequate support from local and national authorities Planning the field operation

steps of investigation
the sequence is not important!
1. 2. 3. Confirm the existence of the outbreak Verify the diagnosis and determine the etiology of the disease Develop a case definition, start case-finding and collect information on cases 4. Describe persons, places and times and generate hypothesis 5. Test the hypothesis using an analytical study 6. Carry out necessary environmental or other studies to supplement the epidemiological study 7. Draw conclusions to explain the causes or the determinants of the outbreak based on clinical, laboratory, epidemiological and environmental studies 8. Report and recommend appropriate control measures to concerned authorities at the local, national and if appropriate, international levels 9. Communicate the findings to educate other public health professionals and the general public 10. Follow up the recommendations to ensure implementation of control measures

prepare for field work: Rapid Response Team

Preparations can be grouped into two broad categories:
Scientific and investigative issues, and Management and operational issues

Investigation: knowledge, equipment, specimen collection, transportation, etc. Administration Consultation

confirm the outbreak

Outbreak
n0 observed cases > n0 expected cases

Expected cases
Surveillance data OPD card Hospital Discharge Registry

Be careful of artefacts !!!

Seasonal variation (diarrhea) Notification variation (new surveillance system in place) Diagnostic variation (new technique) Diagnostic mistake (false epidemic)

confirm diagnosis and etiology

Laboratory
Serology Isolation Serotype Toxic agent

Meet the doctors See the patients Visit the laboratories Not necessary to confirm all the cases

confirm outbreak and diagnosis

Is this an Outbreak? What is the diagnosis?

Link between cases? Higher than expected?

Clinical manifestation Laboratory result

Unknown and unclear diagnosis can cause panic due to rumor

develop a case definition and start case-finding

3 questions need to be answered:
Who should be counted as case? Are we missing any cases in the community/hospital? What are the characteristics of case?

develop a case definitioncontd..

Criteria
Clinical and/or biological Time, place, person (restriction)

Different level of confirmation

Confirmed cases Probables Suspects
A case definition is a standard set of criteria for deciding whether an individual should be classified as having the health condition of interest.

develop a case definitioncontd..

Simple and objective Consistent Sensitivity and specificity

Suspected cases
Clinical case definition Enough for immediate action

Confirmed cases
Laboratory confirmed Very few cases

sensitivity vs. specificity

sensitivity

specificity

sensitivity vs. specificity

Many false positives Many specimens to be tested Low% of specimen tested +ve

Danger of overload of cases

sensitivity vs. specificity

Few false positives Fewer specimens to be tested High% specimens tested +ve

Danger of underreporting of cases

case definition
Components Time Place Person Clinical symptoms & signs Source Textbooks Experts Internet

ex: case definition

cholera
Category Suspected Case definition In an area where the disease is not known to be present: severe dehydration or death from acute watery diarrhoea in a patient aged 5 years or more; or In an area where there is a cholera epidemic: acute watery diarrhea, with or without vomiting in a patient aged 5 years or more Not applicable A suspected case that is laboratory-confirmed.( Isolation of Vibrio cholerae O1 or O139 from stools in any patient with diarrhea is the laboratory criteria for diagnosis) Only confirmed cases for a single isolated case All cases to be counted having epidemiological linkage to a confirmed case during epidemic

Probable Confirmed

Case counted

actively find the case

Sources of information
All possible sources (NGOs, local leaders) Hospitals, health centers, laboratories, doctors, nurses Schools, camps, settlements Radio (FM), door to door Snow ball Laboratory

active-case finding
Intensive search for the case in the community, hospitals and other possible areas Aim is to have enough cases to analyze

Source
Review medical records House-to-house visit Telephonic inquiry

Patients in hospitals

Potential spreader!!

Patients in community

benefits of active case-finding

Control measures can be implemented if the etiology of the disease is known and treatable Rapid environmental assessment can be started during the visit to the affected families or villages

In situations in which the outbreak is not localized but wide-spread, the investigator might need to use the media to alert the public about the outbreak. People can then avoid suspected exposures and see a health-care provider if they have developed symptoms compatible with the case definition.

collecting information
At least 4 types of information:
Identifying information
Name, Hospital/Clinic Number, contact person, address of contact

Demographic information
Age, gender, religion, occupation, ethnicity, area of residence, place of work

Clinical information
Signs and symptoms, date of onset, duration of illness, result of diagnostic procedures

Suspected risk factors

History of exposure to risk factors

Identifying Information

Demographic Information

Clinical Information

Risk factors

describe the outbreak in person, place, and time and hypothesis formation
What are the main clinical features? What is the population at risk? What are the risk factors? What are the most likely explanations of how the outbreak began?

data description (person)

Distribution of cases by age, sex, profession (Numerator)
ex: 50 women, 100 men

Distribution of variables in the population from where cases are coming (Denominator)
ex: 1500 women, 1000 men

Compute attack rate

ex: women 50/1500, men 100/1000 Identification of sub-group(s) at risk

description person
infection S. typhi, attack rate by age
Age group (Years) <20 Number of cases 5 Population 7545
Attack rate/100,000

66

20-25 25-30 30-35 >35

38 22 14 8

3489 3123 2989 5445

1089 704 468 146

Total

87

22591

385

data description (time)

Cases distribution by date (hour, week, day) of onset of signs
Onset, peak, decline

Abnormal cases (Outliers)

Epidemic evolution Allow to make hypothesis
Incubation period, pathogen responsible Source of infection/reservoir, kind of transmission Time of exposure

epidemic curve of Hepatitis A incubation: 2-6 weeks

No. of cases

Time of onset

data description (person)

Place of living, place of exposure (work, food, travel) Spot map (cluster, scattered)

Identify person(s) at risk, population at risk, area(s) at risk

generating hypothesis
Starting from:
Descriptive information [P, T, P] Knowledge of the disease Exploratory study on some cases

Explaining:
The causal agent The source The mode of transmission The carrier

generating hypothesis

testing hypothesis
From an epidemiologic point of view, hypotheses are evaluated in one of two ways:
by comparing the hypotheses with the established facts (when you have apparent/obvious clinical, laboratory, environmental, and/or epidemiologic evidence) by using analytic epidemiology to quantify relationships and assess the role of chance (when circumstances are not as straightforward, and information from the series of cases is not sufficiently compelling or convincing)

Generally tested by analytical study design Either case-control study or cohort study Can be supplemented using a combination of environmental evidence and laboratory science

case-control study

A person who ate the bamboo shoots was 201 times more likely to be ill than a person who did not eat...
Source: Wongwatcharapaiboon P, EIS Conference 1999

Number and percentage of reported exposures associated with influenza A (H5N1) disease by type of exposure, Thailand 2004
Exposure (n=80)
Number of reported exposure (%)

Matched odds ratio (95% CI)

Case (n=16)
Directly touching abnormal dead poultry Dressing poultry Having abnormal dead poultry around the house Plucking dead poultry Being within 1 metre of dead poultry Storing sick/dead poultry products in the house Directly touching sick poultry Being within 1 metre of sick poultry Contact with suspected/confirmed H5N1 human case Visiting live poultry market

Control (n=64) 12 (19) 4 (6) 9 (14) 3 (5) 16 (25) 3 (5) 29 (2.7-308.2) 17 (1.6-177.0) 14 (2.4- 81.6) 14 (1.3- 152.5) 13 (1.8-96.3) 9.3 (2.1-41.3)

10 (63) 5 (31) 8 (50) 4 (25) 10 (63) 7 (44)

8 (50)
9 (56) 3 (19) 1 (6)

9 (14)
14 (22) 13 (20) 0 (0)

5.6 (1.5-20.7)
3.8 (1.2-11.7) 0.9 (0.2-4.4) NA

Source: Areechokchai et al. 2006

retrospective cohort study

A person who ate the fermented vegetable was 6.2 times more likely to be ill than a person who did not eat...

laboratory study, environmental study (supplementary)

Outbreak of unknown illness in a rural village of Egypt Cases
Severe abdominal pain, persistent vomiting, generalized weakness

Laboratory (abnormally high blood lead level) Analytical (association between high blood level and eating flour from one mill factory) Environmental (lead smelting pot in the corner of the mill)
Source: Abdel-Nasser 1996

establish the causes

Compare the results
Laboratory evidence Clinical evidence Environmental evidence Epidemiological evidence (statistical tests)

on-site reporting and recommendation

Report the findings to responsible body (local & national level) Present the main findings with recommendations

Timely response, stop further spread, prevent future outbreak

at the end
Prepare report Evaluate performance Influence public health policy Communicate findings

disseminate information
Educate public health community and the general public Aware other communities

Through
Mass media National/international journal Bulletin Report Telecommunication

follow-up
Maintain close communication with health authorities Ensure implementation of control measures

dont forget !!!

Ethical aspects (animals, ) Respect the participants (informed consent, confidentiality) Local debriefing

The art of epidemiological reasoning is to make some reasonable conclusions starting from imperfect data -George W Comstock