SPM - Investigation of Epidemic

Investigation of epidemic
Dr. K.Kiruthika
• Epidemic : The “unusual” occurrence in a community or
region of the disease, specific health related behaviour or other
health related events clearly in excess of “expected
occurrence”
• Outbreak: It is used for a small, usually localized epidemic
• Endemic : The constant presence of a disease or infectious

agent within a given geographical area or population group,
without importation from outside. e.g. Hepatitis A, cholera
• An epidemic investigation calls for inference as well as
description
• Frequently, epidemic investigations are called for after
the peak of the epidemic has occurred
• In such cases, the investigation is mainly retrospective
• However, in investigating an epidemic, it is desired to
have an orderly procedure or practical guidelines as
outlined below which are applicable for almost any
epidemic study
Objectives of an epidemic investigation
a. To define the magnitude of the epidemic or outbreak
involvement in terms of time, place and person
b. To determine particular conditions and factors responsible

for the occurrence of the epidemic
c. To identify the causative agent, sources of infection, and

modes of transmission
d. To make recommendations to prevent recurrence

Steps in investigation
• Verification of diagnosis
• Confirmation of existence of an epidemic
• Defining the population at risk
• Rapid search for all cases & their characteristics
• Data analysis
• Formulation of hypothesis
• Testing of hypothesis
• Evaluation of ecological factors
• Further investigation of population at risk
• Writing the report
Verification of diagnosis
• The report may be spurious due to misinterpretation of signs
or symptoms by public or health worker
• It is not necessary to examine all the cases
• A clinical examination of a sample of cases is sufficient
• Laboratory investigations wherever applicable, are most

useful to confirm the diagnosis but control measures should
not be delayed until laboratory results are available
Case definition:
• Is needed to identify and count the cases in order to determine
who may be affected by the epidemic
• Components of the case definition may include information
about time and place of exposure, clinical signs & symptoms
and lab findings
• Suspect: A case with specific signs and symptoms during
specific period of time
• Confirmed: A suspected case with laboratory confirmation
• Probable: A case which has unique clinical or preliminary lab
test results during that period
Confirmation of existence of an epidemic
• Done by comparing the number of cases with disease
frequencies during the same period of previous years
• In case of endemic diseases like cholera, typhoid hepatitis A, it

is expected that some cases (few hundreds) always present
throughout the year
Defining the population at risk
Obtaining the map of the area
• It should contain information about natural landmarks, roads
and location of all dwelling units along each road
• The area may be divided into segments, using natural

landmarks as boundaries
• This is again divided into smaller sections. Within each

section, the dwelling units may be designated by numbers
Defining the population at risk
Counting the population
• By doing census by house to house visits. The composition
should be known by age and sex
• Eg: For population at risk. In case of food poisoning- those

who ate the food. In case of outbreak of cholera- those who
were using water from the suspected well
Rapid search for all cases & their
characteristics
Surveillance:
• It has been defined as "the continuous scrutiny of all aspects of
occurrence and spread of disease that are pertinent to effective
control“
• The ultimate objective of surveillance is prevention
• Surveillance, if properly pursued, can provide the health
agencies with an overall intelligence and disease-accounting
capability
• Surveillance is an essential prerequisite to the rational design
and evaluation of any disease control programme
characteristics
• Individual surveillance : This is surveillance of infected
persons until they are no longer a significant risk to other
individuals
• Local population surveillance : e.g., surveillance of malaria,
• National population surveillance : e.g., surveillance of
smallpox after the disease has been eradicated
• International surveillance : At the international level, the
WHO maintains surveillance of important diseases (e.g.,
influenza, malaria, polio, etc.) and gives timely warning to all
national governments
characteristics
• Medical survey
• It should be carried out in the defined area to identify all cases
including those who have not sought medical care, and those
possibly exposed to risk
• By the administration of epidemiological case sheet

characteristics
Epidemiological case sheet
• This should be carefully designed to collect relevant
information
• If the epidemic is large it may not be possible to examine all

the cases. In such cases random sample should be examined
characteristics
Searching for more cases
• The patient is asked about the similar cases at home, family,
neighbourhood, school, work place having an onset within the
incubation period of index case
• The search for new cases should be carried out everyday till
the area is declared free of epidemic
Data analysis
It has to be done using the parameters – Time, Place And Person.
Time:
• Prepare a chronological distribution of dates of onset of cases
and construct an “epidemic curve”. An epidemic curve
suggests :
 Pattern of spread
 Magnitude
 Outliers
 Exposure and/or disease incubation period
Data analysis
Place:
• Prepare a ‘spot map’ of cases and if possible their relation to
the sources of infection e.g. water supply, air pollution, foods
eaten, occupation etc.
• The map shows the boundaries and patterns of disease
distribution. Clustering of cases indicate a common source of
infection
Data analysis
Person
• Analyze the data by age, sex, occupation and other possible
risk factors
• Determine the attack rates/case fatality rates
The purpose of data analysis is
1. To determine modes of transmission and the source and the
vehicle of the agent, so that the most effective measures can be
initiated
2. To determine the risk factors for disease
Formulation of hypothesis
• Hypothesis is a proposition or a tentative theory designed to
explain the observed distribution of the disease in terms of
causal association of the direct nature.
The hypothesis should explain the epidemic in terms of :
1. Causative agent
2. The possible source
3. Possible modes of spread
4. The environmental factors which enabled it to occur
Testing of hypothesis
• All reasonable hypotheses need to be considered and weighed
by comparing the attack rates in various groups for those
exposed and those not exposed to the each suspected factor
• This will enable the epidemiologist to ascertain which

hypotheses is consistent with all the known facts
Evaluation of ecological factors
• An investigation of the circumstances involved should be
carried out to undertake appropriate measures to prevent
further transmission of the disease
• The ecological factors which have made the epidemic possible
should be investigated such as sanitary status of eating
establishments, breakdown in the water supply system,
changes such as temperature, humidity, and air pollution,
population dynamics of insects and animal reservoirs etc..
• In case of water-borne transmission is suspected
(gastroenteitis) a sanitary survey of water supply system from
source to consumer should be done.
Further investigation of population at risk
• This may involve medical examination, screening tests,

examination of suspected food, faeces or food samples,
biochemical studies, assessment of immunity status etc.
• This will permit classification of all members as to
1. Exposure to specific potential vehicles
2. Whether ill or not
Writing the report
Background
• Geographical location
• Climatic conditions
• Demographic status (population pyramid)
• Socioeconomic situation
• Organization of health services
• Surveillance and early warning systems
• Normal disease prevalence
Writing the report
Historical data
• Previous occurrence of epidemics
- of the same disease
- locally or elsewhere
• Occurrence of similar diseases
- in the same area
- in other areas
• Discovery of the first cases of the present outbreak
Writing the report
Methodology of investigations
• Case definition
• Questionnaire used in epidemiological investigation
• Survey teams
• Household survey
• Collection of laboratory specimens
• Laboratory techniques
Writing the report
Analysis of data
• Clinical data
- frequency of signs and symptoms
- course of disease
- differential diagnosis
- sequelae or death rates
• Epidemiological data
- Mode of occurrence
- In time
- By place
- By population groups
Writing the report
Control measures
• Definition of the strategies and methodology of
implementation
- constraints
- results
• Evaluation
- significance of results
- cost/effectiveness
• Preventive measures
Writing the report
• It may be necessary to implement temporary control measures
at the commencement of an epidemic on the basis of known
facts of the disease
• These measures may be modified or replaced in the light of
new knowledge acquired by the epidemic investigation
Uses of writing report
• Health Administrator/Manager: for planning and
implementation of control/ eradication strategies
• Clinician: to update clinical knowledge & make alterations
in case management & diagnostic methods
• Research: For clues & basis for further need oriented
research programmes
• General Population: for sense of security, health educational
tool and to develop confidence in the health care delivery
system

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Investigation of epidemic

• Outbreak: It is used for a small, usually localized epidemic

• Endemic : The constant presence of a disease or infectious

b. To determine particular conditions and factors responsible

c. To identify the causative agent, sources of infection, and

d. To make recommendations to prevent recurrence

• It is not necessary to examine all the cases

• A clinical examination of a sample of cases is sufficient

• Laboratory investigations wherever applicable, are most

• In case of endemic diseases like cholera, typhoid hepatitis A, it

• The area may be divided into segments, using natural

• This is again divided into smaller sections. Within each

• Eg: For population at risk. In case of food poisoning- those

• By the administration of epidemiological case sheet

• If the epidemic is large it may not be possible to examine all

• This will enable the epidemiologist to ascertain which

• This may involve medical examination, screening tests,

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