Outbreak investigation, response and control IDSP training module for state and district surveillance officers Module 8

Learning objectives (1/3) Define an outbreak/epidemic List the various ways of detecting an outbreak/ epidemic List the modes of transmission of causative agents of outbreaks Describe warning signs of an impending outbreak

Learning objectives (2/3) Specify the operational threshold levels of diseases under surveillance for outbreak investigations List the members of rapid response team in your district Enumerate the situations when DEIT would be initiated Describe the steps of epidemic investigation to establish an outbreak and determine its etiology

Learning objectives (3/3) Outline the appropriate control measures to be taken when the nature of the outbreak is established: Water borne diseases Vector borne diseases Vaccine preventable disease outbreaks Outbreaks of unknown etiology

Definition of an outbreak Occurrence in a community of cases of an illness clearly in excess of expected numbers The occurrence of two or more epidemiologically linked cases of a disease of outbreak potential constitutes an outbreak (e.g., Measles, Cholera, Dengue, Japanese encephalitis, or plague)

Outbreak and epidemic: A question of scale Outbreaks Outbreaks are usually limited to a small area Outbreaks are usually within one district or few blocks Epidemics An epidemic covers larger geographic areas Epidemics usually linked to control measures on a district/state wide basis Use a word or the other according to whether you want to generate or deflect attention

Endemic versus epidemic Endemicity Disease occurring in a population regularly at a usual level Tuberculosis, Malaria Epidemics Unusual occurrence of the disease clearly in excess of its normal expectation In a geographical location At a given point of time

Sources of information to detect outbreaks Rumour register To be kept in standardized format in each institution Rumours need to be investigated Community informants Private and public sector Media Important source of information, not to neglect Review of routine data Triggers

Early warning signals for an outbreak 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 meningitis, measles Unusual isolate Shifting in age distribution of cases High vector density Natural disasters

Objectives of an outbreak investigation Host Environment Agent An outbreak comes from a change in the way the host, the environment and the agent interact: This interaction needs to be understood to propose recommendations Verify Recognize the magnitude Diagnose the agent Identify the source and mode of transmission Formulate prevention and control measures

Outbreak preparedness: A summary of preparatory action Formation of rapid response team Training of the rapid response team Regular review of the data Identification of ‘outbreak seasons’ Identification of‘outbreak regions’ Provision of necessary drugs and materials Identification and strengthening appropriate laboratories Designation of vehicles for outbreak investigation Establishment of communication channels in working conditions (e.g., Telephone)

Basic responses to triggers There are triggers for each condition under surveillance Various trigger levels may lead to local or broader response Tables in the operation manual propose standardized actions to take following various triggers Investigations are needed in addition to standardized actions

Levels of response to different triggers Significance Levels of response 1 Suspected /limited outbreak Local response by health worker and medical officer 2 Outbreak Local and district response by district surveillance officer and rapid response team 3 Confirmed outbreak Local, district and state 4 Wide spread epidemic State level response 5 Disaster response Local, district, state and centre

Importance of timely action: The first information report (Form C) Filled by the reporting unit Submitted to the District Surveillance Officer as soon as the suspected outbreak is verified Sent by the fastest route of information available Telephone Fax E-mail

The rapid response team Composition Epidemiologist, clinician and microbiologist Gathered on ad hoc basis when needed Role Confirm and investigate outbreaks Responsibility Assist in the investigation and response Primary responsibility rests with local health staff

The balance between investigation and control while responding to an outbreak Source / transmission Known Unknown Etiology Control +++ Investigate + Control + Investigate +++

Steps in outbreak response Verifying the outbreak Sending the rapid response team Monitoring the situation Declaring the outbreak over Reviewing the final report

Step 1: Verifying the outbreak Identify validity of source of information to avoid false alarm/a data entry error Check with the concerned medical officer: Abnormal increase in the number of cases Clustering of cases Epidemiological link between cases Occurrence of some triggering event Occurrence of deaths

Step 2: Sending the rapid response team Review if the source and mode of transmission are known If not, constitute team with: Medical officer Epidemiologist Laboratory specialist Formulation of hypothesis on basis of the description by time, place and person Does the hypothesis fits the fact YES: Propose control measures NO: Conduct special studies

Investigating an outbreak

Outlying case-patient might have been a source Time Acute hepatitis by week of onset in 3 villages, Bhimtal block, Uttaranchal, India, July 2005 90 Outlying case-patient might have been a source 80 70 60 This graph represents the number of cases by week of onset between the month of May and September 2005 in the the tree villages. The first case in the area developed an illness during the first week of May. The outbreak peaked during the fourth week of July – when the investigated began – and the number of cases decreased during the early part of the month of August. The shape of the curve suggested a common source outbreak. You can see on this graph that before the outbreak, there were a number of initial cases that could be considered as index cases. 50 Number of cases 40 30 20 10 3rd week 1st week 1st week 2nd week 3rd week 4th week 1st week 2nd week 4th week 1st week 3rd week 4th week 1st week 3rd week 2nd week 2nd week 4th week May June July August September Week of onset

Place Incidence of acute hepatitis by source of water supply, Bhimtal block, Uttaranchal, India, July 2005 Water supply Spring Reservoir Pipeline Attack rate < 5% 5-9% 10% + Dov Mehragaon main village This map shows the three villages where the outbreak was reported, including Mehragaon (that you can see on the right and on the centre), Chauriagon (that you can see at the bottom left of the slide) and Dov that you can see on the top left of the slide. We represented each of these villages with a colour representing the attack rate on a yellow to red scale. The yellow denotes the lowest incidence and the red the highest incidence. The blue elements on the slide represent the water supply system, including the springs, the reservoirs shown as blue rectangles and the pipelines shown as blue arrows. As you can see, Dov that had its own spring had the lowest incidence in yellow. Chauriagon that shared a spring with Mehragon had an intermediate in orange and Mehragon that had almost only one source of water supply had the highest incidence in red. On the basis of the attack rate by villages, we generated the hypothesis that the spring that supplied both Mehragon and Chauriagon was the source of the outbreak. Suspected spring Mehragaon Hydle colony Mehragaon Chauriagaon

Person Incidence of acute hepatitis by age and sex in 3 villages, Bhimtal block, Uttaranchal, India, July 2005 Population Cases Attack rate Age 0-4 105 2 2% (Years) 5-9 110 4 4% 10-14 134 23 17% 15-44 729 139 19% 45+ 261 37 14% Sex Male 724 115 16% Female 514 90 Total 1238 205 This graph represents the incidence of acute hepatitis by age and sex in the 3 villages. You can see that the attack rate was highest among persons 15 to 44 years of age (19%) followed by the 10 to 14 years of age (17 %) and by those 45 years of age or older (14 %). The lowest attack rate was found among children under 9 years of age. Female were slightly more affected than males.

When to ask for assistance from the state level? Unusual outbreak High case fatality ratio Unknown etiology Trigger level three and above

Requires assistance from qualified field epidemiologist (FETP) Steps of a full outbreak investigation using analytical epidemiology to identify the source of infection Determine the existence of an outbreak Confirm the diagnosis Define a case Search for cases Generate hypotheses using descriptive findings Test hypotheses based upon an analytical study Draw conclusions Compare the hypothesis with established facts Communicate findings Execute prevention measures E.g.; for practices associated with meth use Requires assistance from qualified field epidemiologist (FETP)

Cohort to estimate the risk of hepatitis by water supply, Mehragaon village, Uttaranchal, India, July 2005 Cases Total Incidence Relative risk (95% C. I.) Use of water from suspected spring to drink No 12 143 9.2% Reference Partially 13 94 13.8% 1.6 (0.8-3.4) Exclusively 152 529 28.7% 3.4 (2.0-6.0) To test this hypothesis, we conducted a cohort study in Mehragaon village to estimate the strength of the association between illness and the source of water supply. The highest attack rate (28.7 %) was among the people using exclusively the suspected spring water. There was an intermediate attack rate (13.8 %) among those who partially used the suspected spring water. The lowest attack rate ( 9.2 %) was among those who never used the suspected spring water. This association between illness and the suspected spring water, along with a dose response relationhsip suggested that the suspected springwas indeed the source of infection. Analytical epidemiology compares cases and non cases or exposed versus unexposed to test the hypothesis generated on the basis of the time, place and person description C.I.: Confidence interval

3. Monitoring the situation Trends in cases and deaths Implementation of containment measures Stocks of vaccines and drugs Logistics Communication Vehicles Community involvement Media response

4. Declaring the outbreak over Role of the district surveillance officer / Medical health officer Criteria No new case during two incubation periods since onset of last case Implies careful case search to make sure no case are missed

5. Review of the final report Sent by medical officer of the primary health centre to the district surveillance officer / medical and health officer within 10 days of the outbreak being declared over Review by the technical committee Identification of system failures Longer term recommendations

Managerial aspects of outbreak response Logistics Human resources Medicines Equipment and supplies Vehicle and mobility Communication channels Information, education and communication Media Daily update

Control measures for an outbreak General measures Till source and route of transmission identified Specific measures, based upon the results of the investigation Agent Removing the source Environment Interrupting transmission Host Protection (e.g., immunization) Case management

Specific outbreak control measures Waterborne outbreaks Access to safe drinking water Sanitary disposal of human waste Frequent hand washing with soap Adopting safe practices in food handling Vector borne outbreaks Vector control Personal protective measures Vaccine preventable outbreaks Supplies vaccines, syringes and injection equipment Human resources to administer vaccine Ring immunization when applicable

Reports Preliminary report by the nodal medical officer (First information report) Daily situation update Interim report by the rapid response team Final report

Points to remember Outbreaks cause suffering, bad publicity and cost resources Constant vigil is needed Prompt timely action limits damage Emphasis is on saving lives Don’t diagnose every case once the etiology is clear Management of linked cases does not require confirmation The development of an outbreak is followed on a daily basis Effective communication prevents rumours Use one single designated spoke person Learn lessons after the outbreak is over