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Disease Outbreak Investigation and Response
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What are the leading causes of death among children under 5?
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Leading Causes of Childhood Deaths
Source: WHO estimates of the causes of death in children, 2000-03 Bryce, Lancet, 26 March 2005
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Where do 10 million children die each year?
WHO estimates of the causes of death in children, Lancet, 2005
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What are the major causes of under 5 deaths in emergency settings?
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Major Causes of Death in Emergencies for <5 Years
Sudan: Wad Kowli CampFebruary, 1985
Somalia: Gedo Region 7 Camps, January, 1980
Source: Centers for Disease Control and Prevention, Famine-Affected, Refugee, and Displaced Populations: Recommendations for Public Health Issues. MMWR, 1992;41(No. RR-13):8.
MeaslesARIMalariaDiarrheaOther
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Examples of Recent Outbreaks
Cholera – Kenya, South Sudan Measles – Aceh, South Sudan, Kenya Yellow fever – South Sudan Meningitis – Darfur Hepatitis E – Darfur Dysentery – Liberia Malaria – Ethiopia, Uganda
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Outbreak Investigations
Why investigate an outbreak?
When to investigate?
How to investigate?
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Why investigate an outbreak ?
Public Health rational
• To design control and preventive measures
• To reduce morbidity
• To reduce or prevent mortality Delayed or improper interventions = DEATHS
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Investigation allows us to (1):
Identify the causative agent• New pathogen causing new disease, e.g. HIV 1984..• Old pathogen causing this outbreak (e.g. Hep E,
salmonella)• Toxic substances (e.g. insecticides, heavy metals, etc.)
Identify modes of transmission• Design effective and efficient interventions
Identify who is at risk• Geographic location• Age or sex group• Occupation• Other
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Investigation allows to (2):
Evaluate health services (e.g., vaccine efficacy) Evaluate public health interventions Evaluate the surveillance system
• Sensitivity, specificity etc. Contribute to medical knowledge Communicate and advocate
TAKE ACTION: disease control and prevention
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Investigation requires:
Basic medical & public health knowledge Basic concepts of epidemiology Sources of specialized information (e.g. reference
books & specialists) Knowledge of the environment Laboratory testing (but not always) COMMON SENSE !
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But before investigating an outbreak…
PREPARE for an outbreak if it is likely!!
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Steps in Investigating an Outbreak
1) What are the steps in investigating an outbreak?
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Steps in Investigating an Outbreak (1)
1) Establish the existence of an outbreak
2) Confirm the diagnosis
3) Define a case and count cases
4) Perform descriptive epidemiology (person, place and time)
5) Determine who is at risk
6) Develop hypotheses explaining exposure & disease
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Steps in Investigating an Outbreak (2)
7) Evaluate hypotheses
8) As necessary, reconsider/refine hypotheses and execute additional studies
• additional epidemiologic studies
• other types of studies – laboratory, environmental
9) Communicate findings
• written report
• presentations
10) Implement control and prevention measures
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Confirm the Existence of an Outbreak
Definition of outbreak
• One case – for diseases of epidemic potential (e.g., measles, cholera)
• More than the expected number of cases – for endemic diseases
• Sometimes is quantitative threshold (e.g.meningococcal meningitis)
Importance of a good surveillance system for early warning
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Monthly malaria admissions and rainfall, Wajir,1996-98
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Malaria admissions
Rainfall
Substantial Rise in Malaria Cases
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Weekly incidence of meningitis, MSF/MOH/Epicentre, Mali, 1997
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Confirm the Diagnosis
Talk with health workers Examine cases yourself ! Laboratory testing (e.g., malaria, cholera,
hemorrhagic fevers, etc.)
Exaggeration of reported outbreaks is common
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Develop a Case Definition
Must be easily applied by health workers
• Preferably does not require laboratory results
• Short time with each patient Must be standardized Should be relatively sensitive
• Detect most cases
• May pick up false positives
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Develop a Case Definition
Measles: 3 possible case definitions Fever and runny nose? Fever and rash and Koplik’s spots and
conjunctivitis? CDC case definition: generalized maculopapular
rash > 3 days and fever and at least one of the following: cough, coryza or conjunctivitis?
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Develop a Case Definition
Measles: 3 definitions Fever and runny nose
• Too sensitive• Too many other illnesses produce same symptoms• Call many illnesses “measles”
Fever and rash and Koplik’s spots and conjunctivitis
• Too specific• Many cases of measles do not have all these signs• Miss many real cases of measles
CDC case definition: generalized maculopapular rash > 3 days and fever and at least one of the following: cough, coryza or conjunctivitis
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Develop a Case Definition
Sometimes define levels of certainty regarding diagnosis; for example, meningitis or Ebola
Confirmed case: laboratory confirmed
Probable case: fits all components of clinical case definition
Possible case: suggestive clinical signs but not fit case definition
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Once Case Definition is Established
Count cases !
Reinforce passive surveillance Active case finding
You do not have to count all cases, but
• What proportion should be detected?
• Depends on what you do with data
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Descriptive Epidemiology
TIME, PLACE, PERSON May be possible to answer:
• Who is at risk?
• What is source of infection?
• What is mode of transmission?
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Descriptive Epidemiology - Time
Distribution of cases by date of onset
X axis: time Y axis: number of cases
Shows:• Time limits / duration of the outbreak• Peak / incubation period• Form of curve: evolution of outbreak• Formulate hypothesis regarding source
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Epidemiologic Curve
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Epidemiologic Curve
0123456789
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Epidemiologic Curve
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Descriptive Epidemiology - Person
Numerators
• Describe cases in terms of • age, sex, • other parameters : refugee / displaced /
residents• immunized , not immunized
Denominators
• Distribution in the overall population (age, sex,...) Compare rates to identify high risk groups
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Descriptive Epidemiology - Place
Map cases: identify geographic places at risk
Determine where disease acquired: Home, work, travel, etc..
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John Snow’s Map of Cholera Cases
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Yambuku 4.5Yamolembia 2.6 Yamisole 2.7
Badjoki 1.8
Bongola 1.6
Yalosemba 1.0
Yaeto-Liku 1.3
Yasoku 0.2
Yambala 0.7Yambala 0.1
Kokoko 0.8 Modjambole 0.8
Yapiki 0.7
Ebola epidemic, Yambuku, Zaire 1976
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Information to Collect on Cases
Personal information Age Sex Place of residence (address) Other relevant “exposures”
• Refugees vs locals
• Food source
• Water source Ethnicity, religion, etc.
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Information to Collect on Cases
Disease data Date of onset of symptoms Clinical symptoms and signs Immunized or not (measles, meningitis) Laboratory results (if any) Duration of disease, outcome (death, cured,..) Treatment received
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Develop Hypotheses
Often obvious from descriptive epidemiology Formulate idea about source of outbreak and
mode of transmission
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Test Hypotheses
Cross – sectional study? Cohort study Case – control study
• Identify cases
• Select control group• Possibly matched on age or sex or location• Community control, clinic control etc.
• Compare exposures among cases and controls
• Calculate odds for various exposures
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Write a Report
Clarifies your own ideas / synthesis Presents data and conclusions to anyone
interested
• Often epidemiologist don’t implement interventions
• Must communicate to those who will intervene Advocacy: MOH, UN, other NGOs, donors Basis for future reference
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Implement - Take ACTION
Interventions include Prevention of further cases Control of transmission and source of infection Improve case management, lower case-fatality
rate
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What would SAVE’s role be in responding to an outbreak?
Outbreak of acute watery diarrhea confirmed as cholera?
Large cluster of measles cases in displaced persons camp?
Sharp increase in measles cases in which SAVE is supporting clinical services ?
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What preventive measures can be taken to reduce likelihood of an outbreak?
Measles? Cholera? Dysentery? Meningitis? Malaria?
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Exercise
SAVE supports clinical services in a large IDP camp with 75,000 persons. A large number of cases of acute jaundice syndrome is detected and local physicians suspect hepatitis. Your clinicians report several deaths among adult women.
What would you do to investigate or confirm this?
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Exercise – part 2
Laboratory confirms agent is Hepatitis E. Over 1000 cases have been reported at your clinics. You suspect there are more cases in the camp that have not come to the clinic.
What other epidemiologic information would you like to see? What environmental information?
What would you do about those not coming to the clinics?
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Exercise part 3
An active case search is conducted and more than 3500 cases are detected. Water sources include water from distribution system (sometimes chlorinated), hand pumps. Some persons collect water from streambeds. There are approximately 100 latrines in the camp.
What do you recommend on the prevention
side?
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Example part 4
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Steps Taken
Chlorination of all water sources (week 32)
Latrine construction Hygiene promotion and
soap distribution Active surveillance