School of Epidemiology, Public Health and Preventive Medicine Back to Basics, 2015 POPULATION HEALTH: Infectious Diseases and Outbreak Investigation Dr. Nicholas Birkett School of Epidemiology, Public Health and Preventive Medicine 03/2015

78-5 Outbreak Management (1) Key Objectives Know the defining characteristics of an outbreak and how to recognize one when it occurs. Demonstrate essential skills involved in controlling an outbreak and its impact on the public, in collaboration with public health authorities as appropriate. 03/2015

78-5 Outbreak Management (2) Enabling Objectives Define an outbreak An excessive number of cases beyond that usually expected. Describe and understand the main steps in outbreak management and prevention. Demonstrate skills in effective outbreak management including infection control when the outbreak is due to an infectious agent. 03/2015

78-5 Outbreak Management (3) Enabling Objectives (cont) Describe the different types of infection control practices and justify which type is most appropriately implemented for different outbreak conditions. Demonstrate effective communication skills with patients and the community as a whole. Describe appropriate approaches to prevent or reduce the risk of the outbreak recurring. 03/2015

78-5 Outbreak Management (4) Enabling Objectives (cont) Understand key features of communicable diseases Understand communicable disease epidemiology 03/2015

78-5 Outbreak Management (5) Physicians are crucial participants in the control of outbreaks of disease. Must be able to Diagnose cases Recognize outbreaks Report these to public health authorities Work with authorities to limit the spread of the outbreak. Common example Assist in the control of an outbreak of influenza or diarrhoea in a nursing home 03/2015

Infectious Disease Summary Terminology Nature of diseases Outbreaks/epidemics Identification Methods of control 03/2015

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Infections: Sources and agents (1) Foodborne Botulism Clostridium perfringens Hepatitis A Norovirus Salmonellosis Shigellosis Staphylococcal disease Trichinosis Person-to-person spread Aseptic meningitis Hepatitis B and C Respiratory Infections (e.g., influenza) Herpes simplex Streptococcal disease Tuberculosis Leprosy Water & Foodborne Amebiasis Cholera Giardiasis Legionellosis E coli 03/2015

Infections: Sources and agents (2) Vaccine preventable Chickenpox Diphtheria, pertussis, tetanus Hepatitis A and B HPV Influenza Measles, mumps, rubella Meningococcal Pneumococcal Poliomyelitis Arthropod Borne Encephalitis (West Nile) Lyme Disease Malaria Plague Rocky Mountain Spotted Fever Zoonotic Psittacosis Q fever Rabies Hantavirus West Nile Prions Kuru vCJD Sexually Transmitted HIV/AIDS Gonorrhea Syphilis Chlamydia trachomatis Fungal Candidiasis Coccidioidomycosis Histoplasmosis 03/2015

Terminology (1) Infectivity Pathogenicity Pathogen The ability of an agent to invade and multiply in a host (an infection). Dose of organism required to establish infection in 50% of animals. Pathogenicity The ability of an agent to produce clinically apparent illness. Pathogen Infectious and non-infectious substances capable of producing tissue damage or initiating a process which can lead to a disease. 03/2015

Terminology (2) Virulence Immunogenicity The proportion of clinical cases which produce severe disease and/or permanent sequelae. Immunogenicity The ability of an agent to produce specific immunity against the agent Can be produced in general body or within specific sites such as the GI tract. Determines the ability of an agent to re-infect the same host e.g. measles vs. gonorrhea 03/2015

Terminology (3) Reservoir Fomites (Vehicle) Living organisms or inanimate matter in which infectious agent normally lives and multiplies Fomites (Vehicle) Inanimate objects contaminated with infectious agent (not the reservoir). E.g. toys in a daycare center. 03/2015

Terminology (4) Vector Zoonoses An animate source of an infectious agent. The vector may be infected with the organism (e.g. mosquitoes and malaria) or just be a mechanical carrier (e.g. flies). Usually insects or small mammals such as rodents. Zoonoses Diseases transmitted to humans from animals (e.g. anthrax) Do they develop human-to-human spread Bird flu 03/2015

Terminology (5) Emerging Infectious Disease An infectious disease where the incidence in humans has increased in the past 2 decades or threatens to increase in the near future (CDC) Complex set of diseases and contributing conditions Habitat destruction War Famine Poverty Climate change Genetic Drift 03/2015

Terminology (6) Carrier Index Case Contacts An infected person without apparent clinical disease who remains infectious (e.g. Typhoid Mary) Index Case The first case to be diagnosed in an outbreak Sometimes defined as the first case noticed in the outbreak Contacts People who have possibly been infected due to relevant contact with an infectious case 03/2015

Terminology (7) Attack Rate The probability that people will get ill from the disease. Usually applied in an outbreak situation. Secondary attack rate is new cases or people minus initial case(s). It is used to estimate to the spread of disease in a family, household, dorm or other group environment. Measures the infectivity of the agent and the effects of prophylactic agents (e.g. vaccine) 03/2015

Terminology (8) Secondary Attack Rate Similar to ‘attack rate’ but excludes the index case(s). Formula is: Secondary attack rate is new cases or people minus initial case(s). It is used to estimate to the spread of disease in a family, household, dorm or other group environment. Measures the infectivity of the agent and the effects of prophylactic agents (e.g. vaccine) 03/2015

Terminology (9) Case Fatality Rate (CFR) The probability of death in people with an infection. 03/2015

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Pathogenic Mechanisms (1) Direct Tissue Invasion (Group A Strep) Production of Toxins (Diphtheria) Allergic Host Reaction Resistant/latent infection (carriers) Enhancement of host susceptibility to drugs (e.g. Reye’s syndrome and ASA). Immune Suppression 03/2015

Reservoirs (examples of transmission patterns) Human Human Human Animal Animal Animal Human Animal Vector Vector Human 03/2015

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Virulence Parasite borne diseases are usually more virulent Spread by direct contact requires an alive and active host Agents often lose virulence as an epidemic passes Ebola (previous epidemics) Virulent strains kill host and don’t spread 03/2015

Epidemics (1) Epidemic Pandemic Now often called an ‘outbreak’, especially if localized The occurrence (in a community or region) of a disease/condition/behaviour clearly in excess of normal expectancy Public’s reaction/view differs from technical definition Pandemic An epidemic covering a very wide area and affecting a large proportion of the population Controversial definition Consider H1N1 outbreak 03/2015

Epidemics (2) Endemic the occurrence of a disease/condition at a relatively constant level in a given setting, usually with on-going transmission 03/2015

Epidemics (3) Conditions increasing likelihood of an epidemic Agent conditions Introduction of a new pathogen Increased amount of a pathogen Change in the virulence of a pathogen. Population conditions An adequate number of exposed and susceptible persons. An effective means of transmission between the source of the pathogen and the susceptible person. 03/2015

Epidemics (4) Types of epidemics Epidemic curve Spot maps Common source Point source Ongoing exposure Need not be geographically localized Propagated/progressive Mixed Epidemic curve Spot maps Note that epidemics can arise from behaviour as well as from traditional infectious sources. 03/2015

Epidemic Curves: point source (1) 03/2015

Epidemic Curves: propagated (2) 10 days 03/2015

Average incubation period Minimum incubation period Distribution of cases by onset of symptoms: point source type Maximum incubation period Average incubation period Minimum incubation period Exposure 03/2015

Exposure begins & continues Distribution of cases by onset of symptoms Point source, Continuous exposure type Exposure begins & continues 03/2015

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Factors Influencing Spread of Disease in a Population (1) Period of infectivity in relationship to symptoms Includes consideration of carrier states Herd immunity Type of spread Direct Indirect Airborne Transmission mechanics Consider sexual vs. droplet spread 03/2015

Herd Immunity Develop disease Immune 03/2015

Outbreak Control (1) Twin goals: Goals can conflict: Minimize the impact to the affected community Understand the cause and mode of transmission Goals can conflict: Need to take action in absence of full information Need to collect full information base 03/2015

Outbreak Control (2) Establish the diagnosis Clinical examination History, especially of exposure to: other sick people travel agents Laboratory testing Rapid response vs. definitive tests Determine pattern of spread Type of outbreak Epidemiological study of exposures ‘in common’, etc. 03/2015

Outbreak Control (3) Effective and clear communication with general public is essential Designate one spokesperson Regular press briefings Lessons from the SARS outbreak 03/2015

Outbreak Control (4) General strategies for addressing outbreaks Reduce host susceptibility Interrupt Transmission of the Agent Strategies can be useful for Controlling an active outbreak Preventing the onset of an outbreak 03/2015

Outbreak Control (5) Reduce host susceptibility During an outbreak Immunization (active and passive) Before an outbreak, or during a long outbreak Nutrition Improve living conditions Improve other social determinants of health A large part of the reason that infectious outbreaks are now so uncommon 03/2015

Outbreak Control (6) Interrupt Transmission of the Agent Identify source of outbreak and remove it Quarantine/isolation Case treatment Contract tracing 03/2015

Outbreak Control (7) Interrupt Transmission of the Agent (cont) Food inspections Environmental clean-up Animal population control Rabies vaccination of wild animals Insect spraying Monitor for animal infections 03/2015

Outbreak Control (8) Isolation Applies to propagated epidemics Deals with people who are already ill Separate the infectious persons or animals from others during the period of communicability Usually isolate for at least two incubation periods If incubation period is unknown Try and estimate it based on transmission patterns Be conservative 03/2015

Outbreak Control (9) Quarantine Applies to propagated epidemics Places restrictions on the activities of well people who (may) have been exposed to a communicable disease during its period of communicability. Quarantine for the longest usual incubation period Often at least two incubation periods. ‘active surveillance’ is an alternative 03/2015

Outbreak Control (10) Quarantine (cont) More controversial than isolation since it affects people who are not currently ill (and may never get ill). We expect some people who are quarantined to get sick 03/2015

Outbreak Control (11) Immunization Passive or active Passive can be more useful for acute outbreak control Chemoprophylaxis Treat people with disease Preventive use of antibiotics for people exposed tuberculosis meningococcal infection 03/2015

Outbreak Control (12) Harm Reduction (for long term outbreaks) Focus on prevent adverse effects from harmful exposures Needle exchange Safe Injection sites Inactivate agent water purification; chlorination 03/2015

Outbreak Control (13) A ‘contact’ Need to treat every ‘contact’ Contact tracing Done by the Public Health Department Applies to diseases with person-to-person spread Especially STIs A ‘contact’ Someone who interacted with the index case in such a way that they may have become infected Need to treat every ‘contact’ 03/2015

Outbreak Control (14) Contact tracing (cont) Index case is given chance to contact his/her ‘contacts’ If that doesn’t happen, PHU can take proactive action and contact cases For TB, PHU takes the lead in contact tracing Ensuring preventive treatment using Directly Observed Treatment methods. 03/2015

Outbreak Control (15) Personal hygiene measures hand hygiene (#1 strategy) cough etiquette protective clothing (masks, gowns) avoid at risk situations Family/community measures preventing sexual abuse of children leads to reduction in STIs Needle exchange and related programmes. 03/2015

Surveillance (1) The continuing scrutiny of all aspects of occurrence and spread of disease that are pertinent to effective control Reportable diseases. legal obligation to report designated diseases to local public health department list includes (among many others) AIDS food poisoning encephalitis STIs influenza Lassa fever SARS plus many more 03/2015

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Surveillance (2) The continuing scrutiny of all aspects of occurrence and spread of disease that are pertinent to effective control Reportable diseases. Sentinel practices Animal/water surveys Environmental monitoring Mortality (vital statistics) Provincial laboratory tests Epidemic investigations Disease registries CIHI and related data. 03/2015

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