Professional Documents
Culture Documents
DISEASE NO
OUTBREAK OUTBREAK
12
10
0
1958 1959 1960 1961
Incubation Period: Interval from receipt of infection
to the time of onset of clinical illness.1
Important in case of isolating infected people to prevent
transmission.
Isolation or quarantine should be greater than maximum
incubation period.
Useful if disease may be introduced into new areas.
Quarantine: The restriction of activities of well
persons or animals who have been exposed to a case
of communicable disease during its period of
communicability (i.e. contacts) to prevent disease
transmission during incubation period if infection
should occur.1
From quarante giorni (40 days).
Plague (Black Death) Europe, 1374 – Venetian Republic
1377, Ragusa detained travellers in an isolated area,
initially for 30 days and, when it did not work, for 40 days
Common-source epidemics
Singlesource or point source epidemics
Continuous or multiple exposure epidemics
Propagated epidemics
Person to person
Arthropod vector
Animal reservoir
Example:
Food poisoning due to spoiled food item in a feast.
Bhopal gas tragedy ( 198
Common source multiple exposure: There is only one
source, which provides continuous or intermittent
exposure over a longer period
Example:
Prostitute transmitting STD to her clients
Typhoid Mary
1200 1189
population, during 1000
800
the corresponding 600 600
0
period of the 400
200
0
0
0 0 0 1
4 10
362
213
15
0 0 0 0 0 2 148
101
previous years. 0
1
J F M A M J J A S O N D
months of reporting
• Clustering of cases or deaths
• Increases in cases or deaths
• Single case of disease of epidemic potential
• Acute febrile illness of an unknown etiology
• Two or more linked cases of disease with outbreak
potential(e.g., Measles, Cholera, Dengue, Japanese
encephalitis or plague)
• Unusual isolate (Cholera O 139)
• Unusual presentation
• Environmental factors e.g. rainfall, climate
• Shift in age distribution of cases
• High vector density
• Natural disasters
Rumour register
To be kept in standardized format in each
institution
Community informants
Private and public sector
Media
Important source of information, not to neglect
Review of routine data – surveillance data
Triggers (There are triggers for each condition under
surveillance, Various trigger levels may lead to local or
broader response)
Threshold for diseases under surveillance that trigger pre-
determined actions at various levels
Based upon the number of cases in weekly report
Trigger levels depend on:
Type of disease
Case fatality (Death / case ratio)
Number of evolving cases
Usual trend in the region
Trigger Significance Levels of response
Migrants or refugees
Obtain a map of the area
Counting of the population
Laboratory
Verification +
Clinical
Features ++ ++ +
Example: E. coli O157 outbreak at
Restaurant X on 31/3/2010
Possible: diarrhea (3 loose stools per day) and
ate food purchased at restaurant X on 31/3
Probable: bloody diarrhea and ate food
purchased at restaurant X during on 31/3
Confirmed: culture positive with “outbreak”
PFGE pattern and ate food purchased from
restaurant X on 31/3
Case Definition may need to be updated within
an investigation
Broad to specific
Infectionwith E. coli O157 vs. infection with the outbreak
strain (defined by PFGE pattern)
Location of exposure
SARS outbreak (travel within 10 d of onset):
• In February: China/HK/Hanoi/Singapore
• In April: Toronto, Canada added
• In May: Taiwan added
Dates of exposure can change
SARSoutbreak: to meet the case definition-dates of
exposure dependant on location of exposure
The first cases to be recognized are usually only a small
proportion of the total number
Iceberg phenomenon 40
The information is collected by “line listing”.
A line list is like a nominal roll of the cases being reported
to the various health care establishments (like dispensaries,
general practitioners or admitted to the hospitals)
Constitutes and updates a database of cases
Done by hand or by Excel.
The survey team will go for “door to door” survey
in the affected area and ask if any person had
suffered with symptoms fitting into case definition
(Rapid Household Survey)
If yes, their details were recorded on the
epidemiological case - sheet and required samples
are taken and dispatched to the hospital/ reference
laboratory.
Epidemiological case sheet = Case interview form
Detailed information from the case relevant to the
disease under study.
Information includes:
• Name, Age, Sex, Occupation, Social class
• Time of onset of disease, Signs & Symptoms
• Personal contact at home, work, school
• Travel history, attendance at large gatherings
• History of previous exposure/injections,
• Special events such as parties attended, foods
eaten, and exposure to common vehicles such as
water, food and milk
Active door-to-door collection of information is by
“ Rapid Household Survey”
Characterizing an outbreak by time, place and
person is called descriptive epidemiology.
5+ 51 1,795,383 2.8
Weber JT, Hibbs RG Jr, Darwish A, et al. A massive outbreak of type E botulism associated with
traditional salted fish in Cairo. J Infect Dis 1993; 167: 451-454
What is the exact period of the outbreak?
2. Eyeball
distribution
to choose interval
1. Count cases by
3. Finalize
time of onset
Interpretation of epidemic curve
Shape – type of epidemic
An early case in the curve may represent source of the
epidemic
Give information about the time course of an epidemic
and what the future course might be
In a point-source epidemic of a known disease with a
known incubation period, epidemic curve provides
information to identify a likely period of exposure
Shape of epidemic curve illustrates type of epidemic.
Mean incubation period
Common source single exposure:
Sharp increase followed by a rapid decline.
Continuous common source outbreak:
An abrupt increase in the number of cases but, new cases
persist for a longer time with a plateau shape instead of a
peak before decreasing.
• Intermittent common source:
multiple peaks
Propagated source outbreak:
Increase in the number of cases with progressive peaks
16
14
Number of cases
12
10
8
6
4
2
0
1 4 7 10 13 16 19 22 25 28 31 34
Date
The spatial relationships
of cases are shown best
on a spot map.
A spot map showing
the location of cases can
give an idea of the
source of infection like
maps show that the
cases occurred in
proximity to a body of
water, a sewage
treatment plant, or its
outflow. DRAWING A ROUGH SPOT MAP
Questions to be asked and answered:
What is the most significant geographic distribution
of cases?
Place of residence? Workplace?
Do the attack rates vary by place?
Relation to any landmark or possible source?
Usually we generate hypotheses from the beginning of
the outbreak, however, at this point, the hypotheses
are sharpened and more accurately focused.
What to use?
Case Cohort
control
Rare disease/ large community +++ -
Common disease/ small community - +++
Complete population accessible +/- +++
Large amount of resources + ++
Limited resources +++ -
Example:
Case control study for an outbreak of Acute Gastroenteritis
following a dinner.
ALFAALFA
10 (67) 6 (17) 8.25
SPROUTS
These are additional studies undertaken to
corroborate the findings of the epidemiological
study.
Environmental studies
Microbiological studies
Entomological studies
Environmental studies often help explain why an
outbreak occurred and may be very important in
certain settings.
Example: Site of contamination of irrigation canal with
cattle urine in an outbreak of Leptospirosis in
southeastern Washington, August 1964.
Pond connected to
irrigation canal
And
Cattle around the site
Microbiological studies can clinch the relationship
between suspected source and outbreak.
Example: In the above outbreak of Leptospirosis, culture
of urine from the cattle, water of the canal and blood of
affected children yielded the same strain of L. pomona.
Also, the children who had recovered showed increased
anti leptospiral antibodies.
Entomological studies help identify the vector
responsible for the outbreak.
May also give useful insight into the life cycle of the
pathogen and the mode of transmission
Example:
Vector surveillance
in Chikungunya
affected villages of
Latur and Beed
districts of
Maharashtra, 2006
Additional epidemiologic studies
What questions remain unanswered about the disease?
What kind of study used in a particular setting would
answer these questions?
When analytic studies do not confirm the hypotheses
reconsider the original hypotheses
look
for new vehicles or modes of transmission
Additional investigations
Further lab studies