Types of Epidemics

and
Epidemic Investigations

Professor Tarek Tawfik Amin

Public Health Dept. Faculty of Medicine
Cairo University
amin55@myway.com
 Describing the disease
Pattern of disease may be described by the time of occurrence,
week, month, year, etc
There are three kinds of trends or fluctuations in disease
occurrence:
1-Short term fluctuations (Epidemic)
2-Periodic fluctuations
3-Long term or secular trends
 Types of Epidemics
Common-Source Epidemics:
- Single exposure or point source epidemics.
- Continuous or multiple exposure epidemics.
Propagated Epidemics:
- Person to person.
- Arthropod vector
- Animal reservoir
Mixed Epidemics.
Slow modern Epidemics: NC non-communicable diseases
 I- Common Source Epidemics
(A) Single-exposure point epidemics

-Exposure is Brief and simultaneous (immediate or

concurrent) exposure.
-All cases develop within one incubation period (food
poisoning epidemics).
Features of epidemic curve:
1-Rises and falls rapidly, no secondary waves.
2-Tends to be explosive, with clustering of cases within
narrow interval of time.
3-All cases develop within one incubation period.
 Epidemic curve of point source
1- Commonly due to
infectious diseases
2- May be from environmental
No. of cases
Median I.P pollution

Exposure

I.P
Time
 Single exposure or point source epidemics
(B) Continuous or repeated exposure

Frequently not always due to exposure to an

infectious agent
They can result from contamination of the
environment (air, water, food, soil) by industrial
pollutants
Minamata disease in Japan from consumption of
fish containing high concentrations of methyl
mercury
 Common Source Epidemics
(B) Continuous or repeated exposure
1-The exposure from the same source may be
prolonged-continuous, repeated or
intermittent
2-No explosive rise in number of cases.
3-Cases occur over more than one incubation
period.
Outbreak of respiratory illness, the Legionnaire disease in 1976 in
USA, was a common source, continuous or repeated exposure,
no evidence of secondary cases
 Epidemic curve of repeated exposure

1- Water well exposure.

No. of cases
2- A Nationally distributed
food or other brands.

Exposure

1 I.P
Time
 Common Source Epidemics
(B) Continuous or repeated exposure
Epidemic may start from a common source
and then continue as a propagated epidemic,

Water borne epidemic as example the epidemic reaches a sharp

peak, tails (end) off gradually over longer time of period
 II- Propagated Epidemics
Height Termination phase
Initial period

Primary
case

Susceptible
population

Failed to infect Mostly immune

Infected person Susceptible/Immune
 Propagated Epidemics
Of infectious origin, with person to person
transmission (hepatitis A,E and polio epidemics).
Gradual rise and tails off over longer period of time.
Transmission continues till depletion of susceptible or
susceptible individuals are no longer exposed to source
of infection.
Communicability (speed of spread) depends on herd
immunity among exposed and opportunities for contact
with infective dose and secondary attack rate.
Epidemic Investigations
 Objectives of epidemic investigations

1-Define magnitude of epidemic (time, person,

place) (When, Whom, Where).
2-Determine factors responsible for epidemic
(Why).
3-Identify cause, sources of infection and modes of
transmission (How).
4-Implement control and preventive measures at
commence of epidemic (? Modification).
 Epidemic Investigations
Frequently, epidemic investigation are called
for after the peak of the epidemic has occurred,
retrospective investigation
No step by step approach is applicable like
cook book

It is not necessary to follow the 10 steps in order.

Several tasks can be carried out simultaneously. Saving time
 10 steps of epidemic investigation
1-Verify diagnosis.
2-Confirm existence of epidemic.
3-Define population at risk.
4-Search for cases & their characteristics.
5-Data analysis.
6-Hypothesis formulation.
7-Testing hypothesis.
8-Evaluation of ecological factors.
9-Further investigation of at-risk population.
10-Report writing.
 1-Verify diagnosis
- First step in investigation as sometimes the
epidemic report could be spurious (fake)
- Misinterpretation of signs and symptoms
by the lay public
- Confirm diagnosis (clinical, laboratory and
radiological) quickly on spot on few cases.
-Start epidemiologic investigation.
 2-Confirm existence of epidemic

- Epidemic exists when the number of cases

(observed frequency) is in excess of the expected
frequency for that population, based on past
experience
- An arbitrary limit of 2 SD from the endemic
occurrence is used to define the epidemic
threshold for common diseases as flu.
- Compare with past experience in same locality
(2 SD above mean).
 2-Confirm existence of epidemic
-Point source epidemic (HAV, cholera, food
poisoning) are evident.

-Modern (slow) epidemic (cancer, CVD) are

difficult to recognize.
 3-Defining population at risk

1-obtaining a map of the area: with water

collection, residential areas, designated number
to houses.
2-Population censuses (counting): denominator of
attack rates.
 3:1-Obtaining a map of the area
Before beginning investigation, a detailed and
current map of the area is needed

It should contain information concerning natural

land marks, roads and the location of dwelling units
along each road or in isolated areas

Area into segments divided by natural landmarks,

then into smaller sections then houses
 3:2-Population censuses (counting):
denominator of attack rates.

Denominator may be related to the entire population

or subgroups of a population
If denominator is entire population, a complete
census of the population by age and sex should be
carried out by house to house visit
This helps in computing the much needed attack
rates in groups or subgroups of population
 4-Search for cases & their characteristics

1-Medical survey: examine all population (sample).

2-Epidemiological case sheet: filled for all population
(sample).
Includes: socio-demographics history of exposure S&S special event sources of
suspected vehicle
3-Search for more cases: 2ry cases during IP from last
case till area is declared free
 4:1-Medical survey
Concurrently, medical survey should be
carried out in a defined area to identify
all including those who have not sought
medical care and those at risk
Complete survey will pick all affected
individuals with symptoms and signs of
the disorder
 4:2- Epidemiological case sheet
Interview case sheet, designated according to
the preliminary rapid inquiry to collect
relevant information
Name, age, sex, occupation, social class, travel, history of
previous exposure, time of onset of disease, signs and symptoms,
personal contact, events as parties, exposure to vehicles as
food, water, milk, history of injections, blood products
received
 4:3- Search for more cases
Patient asked if knew other cases at
home, work, neighborhood, school,
Search of new cases (secondary cases)
should be done everyday till the area
declared free of epidemic
This should be twice the incubation
period of disease since occurrence of last
case
 5-Data analysis

- Purpose: Identify common event or experience

and define group involved.
-Time (epidemic curve): suggests time of exposure
and time clustering of cases

The epidemic curve may suggest:

- A time relationship with exposure to a suspected source
- Whether is a common-source or propagated epidemic
- Whether it is a seasonal or cyclic pattern suggestive of a particular infection.
 5-Data analysis

Place (spot map): shows clustering of cases

(common-source) provide evidence of source,
mode of spread like John Snow in the cholera
outbreak in London

- Persons characteristics: age, sex, occupation,

exposed to specific event.

- Determine the attack rates/case fatality rates for

those exposed and non exposed and according to
host factors
 6-Hypotheses formulation

On basis of host-agent-environment formulate

hypothesis to explain epidemic in terms of:

-Possible source.
-Causative agent.
-Possible modes of spread.
-Predisposing environmental factors.
 7-Testing hypotheses

All reasonable hypotheses need to be considered

and weighed by comparing attack rates in
various groups for those exposed and non
exposed to each suspected factor

Consider & test alternative hypotheses to

find which hypothesis is consistent with all
the facts
 8-Evaluation of ecological factors
Epidemiologist concern is to relate the disease to
environmental factors to know source, reservoir
and modes of transmission

-Investigate possible ecological factors:

-Sanitary status of Eating establishment.
-Water & milk supply.
-Population movement.
 8-Evaluation of ecological factors

-Atmospheric changes temperature, humidity,

and air pollution
-Population dynamics of vectors & animal
reservoirs.
-Breakdown in water supply system
 9-Further investigation of at-risk population
*Prospective or retrospective collection of
additional information through:
Clinical examination screening test examination of food, stool or blood
specimen biochemical studies assessment of immunity status.
*Detect sub-clinical cases classify population
according to exposure and illness status into:
1-exposure to specific potential vehicle
2-wether ill or not
 10-Report writing
* Background:
Geographical location
1 Climate condition
2 Demographic status (population pyramid)
3 Socioeconomic status
4 Organization of health services
5 Surveillance and early warning systems
6 Normal disease pattern.
.
 10-Report writing
**Historical data:
- Previous epidemic (same or other dis. In
same or other localities)
Discovery of first case of the present
outbreak.
-Occurrence of related diseases in the same
area or in other areas
 10-Report writing

***Methodology of investigations:
- Case definition
Questionnaire used in investigation
Survey method (household, retrospective)
- Prospective surveillance
- Data collected laboratory specimens and
techniques
 10-Report writing

****Data analysis:
- Clinical (S & S, course, DD, outcome)
Epidemiologic: (time, place & person distribution)
sources & modes of transmission
- Modes of transmission:
Source of infection
Routes of excretion and portal of entry
Factors influencing transmission
 10-Report writing
Laboratory data: (agent isolation, sero-diagnosis and
significance of results)
- Data interpretation:
- Comprehensive picture of the outbreak
- Formulation & testing hypothesis

***** Control measures:

Definition of strategies and methods of implementation
:constraints - results
 10-Report writing

******Evaluation:
*******Significance of results
********cost/effectiveness
********Preventive measures
 Review questions:

-Enumerate types of epidemics and their

characters
-What are the objectives of epidemic
investigation?
-Enumerate steps of epidemic investigation.
 Case Study
A 23-year old male student presented at 10.30 PM on January17 at the
college infirmary complaining of sudden onset of abdominal cramping,
nausea, and diarrhea.
Although the patient was not in severe distress and had no fever or
vomiting, he was weak.
A number of other students, all with the same symptoms, visited the college
infirmary over the next 20 hours.
All patients were treated with bed rest and fluid replacement therapy.
They recovered fully within 24 hours of the onset of illness.
 Calculation of the Attack Rate
Existing information was gathered:
The index case presented 10.30 PM on January 17 and by 8 PM on
January 18, 47 affected students were examined, the attack rate was:
Attack rate (AR) = Number of new cases Persons at risk *
100
Attack Rate (all students) = 47/1164 X100 = 4.0%
Further investigation revealed that:
About 2/3 of the students lived in dormitories, one third lived outside
(not at risk), so a more precise estimate of the attack rate will be:
Attack rate (Dorm. Residents) = 47/756 X100 = 6.2 %.
The dormitory of residence of the 47 cases and the attack rate, as well as the
population and sex of the occupant of each dormitory.

Dormitory Sex Population at Number of Attack rate

risk cases (AR%)
1 F 80 19 23.8
2 F 62 2 3.2
3 F 89 0 0
4 F 61 1 1.6
5 F 53 5 9.4
6 M 35 0 0
7 M 63 0 0
8 F 103 4 3.9
9 M 35 1 2.9
10 M 37 0 0
11 F 34 1 2.9
12 M 62 13 21.0
13 M 32 1 3.1
14 M 10 0 0
- 756 47 6.2
Total
 Calculation of Risk Ratio
Population of dormitories number 1 and 12 were more at risk as their
residents showed the highest attack rate compared to the
remaining dormitories.

Attack rate (dorms. 1,12) = (19+13) / (80+62) X 100 = 22.5 %

Attack rate (remaining dorms) = (47-32) / (756-142) X100 = 2.4 %

A ratio of these attack rate may be calculated as follows:

Risk Ratio = AR (dorm 1,12) = 22.5 % = 9.4

AR (remaining dorm) 2.4 %

It means that the AR in dormitories 1.12, was 9.4 times

greater than in the remaining 12 dormitories.
 Searching for More Cases
Visits to some of the campus dormitories by the
investigators soon revealed that not all students who
became ill had visited the infirmary.
The extent of the outbreak is biased by the different
care-seeking behavior.
Questionnaires were prepared and distributed by hand
to all students living in seven dormitories chosen
randomly to be a representative sample.
A different picture of the epidemic emerged from the results.
 Responses to the questionnaire surveyed by
dormitory.
Questionnaire No. of ill
returned students
Dormitory Population Number %
5 53 49 92.5 13
6 35 26 74.3 13
7 63 28 44.4 15
8 103 65 63.1 21
9 35 19 54.3 5
12 62 44 71.0 22
Nurses* residence 60 60 100 17
Unidentified ** - 13 - 4
Total 411 304 74.0 110

Dormitories 1-4, 10,11,13, and 14 were not surveyed.

Nurse * dormitory was located off campus.
Unidentified ** residence was not entered on 13 questionnaire.
The overall attack rate now will be = 110/304 X100 = 36.2 %
 Why infirmary AR is lower than the
survey AR?
Variation in the severity of illness whose with mild disease
may not seek medical care.
Other may thought care elsewhere including severe cases.
Access to medical care in the sense of distance, money and
availability of the services.
 Features of the Epidemic
More wide spread and explosive nature of the
outbreak as almost 1/3 of the students are affected.
The clustering of cases in relation to time suggested a
common-source exposure.
Data collected during survey indicated that no large gatherings of students
parties, sports events had recently occurred.
Attention then was directed at meals, as most students ate at college
cafeteria, included in the survey were questions concerning the source of
meals eaten on January 16 and 17.
 Analysis of meal-specific exposure histories of the
respondents to the questionnaire.
Students who ate specific meals Students who did not

Ill Well Total AR % Ill Well Total AR %

January 16
breakfast 52 100 152 34.2 51 94 145 35.2
lunch 89 150 239 37.2 20 44 64 31.3
dinner 87 150 237 36.7 23 44 67 34.3

January 17
breakfast 56 105 161 34.8 42 89 131 32.1
lunch 106 145 251 42.2 3 49 52 5.8
dinner 78 130 208 37.5 31 64 95 32.6

The risk ratio of lunch meal on January 17 was:

RR (1/17 lunch) = AR eaters / AR non-eaters = 42.2%/5.8 % = 7.3
Those who eat this meal were more than 7 times to have become
Ill compared to non-eaters.
 Calculation of the incubation period.
Having identified the meal at which the students
most probably were exposed to the casual
pathogen and knowing each students time of
onset of symptoms, it was possible to calculate
the incubation period (the time between eating
the lunch meal on January 17 and the onset of
symptoms).
The median incubation period is the time by which 50 % of the cases
have occurred.
 Distribution of number of cases by time from
eating suspect meal to development of symptoms.

120
100 101
80
Time in number of
60 59
hours 51 students
40 42
33 cumulative
20 22
22 18
11 8
0
8 9 10 11 12
number of cases
Foods Responsible for the Outbreak,
Searching for the Source
 Foods Responsible for the Outbreak, Searching for the
Source
Food or beverages Students who ate specific meals Students who did not

Ill Well Total AR % Ill Well Total AR %

Fish chowder 16 36 52 30.8 87 103 190 45.8
Lamb stew pie 95 56 151 62.9 7 82 89 7.9
Tuna noodle 12 57 69 17.4 92 80 172 53.5
casserol 58 54 112 51.8 39 69 108 36.1
Pineapple jell 32 39 71 45.1 63 82 145 43.4
Fruit salad 4 5 9 44.4 95 126 221 43.0
Cabbage salad 19 29 48 39.6 80 102 182 44.0
Jill with vanilla 62 77 139 44.6 39 56 95 41.1
Jill without 91 127 218 41.7 12 13 25 48.0
Milk 10 31 41 24.4 89 103 192 46.4
Coffee 23 19 42 54.8 78 114 192 40.6
Tea
The risk ratio for certain food was more than 1:
8 for lamb stew pie, which may indicted the source of infection.
 Conditions Favoring Infection
The lamb stew pie through further investigations,
it was revealed that it was prepared on the
previous day (January 16), refrigerated and
warmed on the morning it was served.
What was the causative agent???????????