1. Epidemics and endemic diseases ll Prof. Hamed Adetunji

2. Epidemics CDC

3. What do you understand by the term ‘Epidemic’ or ‘Outbreak’?

4. Solution: An epidemic (or outbreak) is the occurrence of a disease in excess of what is expected in a particular community, for a particular groups of people, within a certain period of time

5. Other Terms Endemic it refers to the constant presence of a disease or infectious agent within a given geographic area or population group. It is the usual or expected frequency of disease within a population Pandemic refers to an epidemic occurring simultaneously in multiple locations world-wide Public Health Disaster Planning at District Level 5

6. Common Epidemic likely diseases Diarrhoeal diseases including watery diarrhoea, Cholera, dysentery and typhoid are likely to occur in many regions Outbreaks of immunisable diseases like measles can be common if immunisation coverage is low Malaria is endemic in most parts of Sub Saharan Africa especially in low land areas; however outbreaks can occur in both low and highland areas

7. Orienting Data by Time Epidemic Curves

8. Descriptive Epidemiology: Time

9. An epidemic curve (epi curve) is a graphical depiction of the number of cases of illness by the date of illness onset Can provide information on the outbreak’s: Pattern of spread Magnitude Outliers Time trend Exposure and / or disease incubation period

10. Epi Curve: Pattern of Spread The overall shape of the epi curve can reveal the type of outbreak (the pattern of spread) Common source Intermittent Continuous Point source Propagated

11. Common Source Outbreak People are exposed to a common harmful source Period of exposure may be brief (point source) long (continuous) or intermittent

12. Epi Curve: Common Source Outbreak with Point Source Exposure Pattern of Spread

13. Epi Curve: Common Source Outbreak with Continuous Exposure Pattern of Spread

14. Epi Curve: Common Source Outbreak with Intermittent Exposure Pattern of Spread

15. Epi Curve: Propagated Outbreak Pattern of Spread

16. Epidemic Curves: Magnitude of the Outbreak Magnitude

17. Epi Curves Provide Information about the Time Trend of an Outbreak Date of illness onset for the first case Date when the outbreak peaked Date of illness onset for the last case Number of cases Days

18. Clues from the Epi Curve Incubation period The time from the moment of exposure to an infectious agent until signs and symptoms of the disease appear Period of exposure Point source outbreak Timeframe during which the exposure likely occurred

19. Using Epi Curves to Estimate the Incubation Period Use when timing of exposure is known and agent is unknown Estimated incubation period is between Time of suspected exposure Time of peak of epi curve

20. Using Epi Curves to Estimate Period of Exposure Use when incubation period for the disease is known Period of exposure is between Peak of epi curve counting back the average incubation period Earliest case, counting back the minimum incubation period

21. Centers for Disease Control. Hepatitis– Alabama. MMWR 1972:21:439-444 Calculating the Exposure Period

22. Creating an Epidemic Curve Cases of Disease X in Y Population, Nov-Dec 2012Number of cases of disease reported during an outbreak plotted on the y-axis Time or date of illness onset plotted on the x-axis Pre-epidemic period included to show the baseline number of cases

23. Creating an Epidemic Curve Cases of Disease X in Y Population, Nov-Dec 2012 Descriptive title Axis labels

24. Epi Curve X-axis Units Depends upon the incubation period Begin with a unit one quarter the length of the incubation period Example: 1. Mean incubation period for influenza = 36 hours 2. 36 x ¼ = 9 3. Use 9-hour intervals on the x-axis for an outbreak of influenza lasting several days

25. Epi Curve X-axis Units For an unknown incubation period Graph several epi curves with different time units Choose units that best represent the data Units may range from hours to months, depending on the outbreak duration and known or suspected incubation period

26. Example X-axis Considerations X-axis unit of time = 1 week X-axis unit of time = 1 day

27. Session Summary Outbreak The occurrence of more cases of disease than expected for a given place and time Outbreak investigation Decision to investigate depends on several factors Verification of the diagnosis allows for identification of the incubation period and is necessary to hypothesize about the exposure Case definition classifies case-patients related to the outbreak and is used to conduct additional case finding

28. Session Summary Descriptive epidemiology Characterizes the outbreak by time, place, and person Is essential for hypothesis generation Measures of central tendency Assess distribution of data Include mean and median Epi curves, spot maps, and line listings are ways to summarize time, place, and person elements of descriptive statistics

29. References and Resources Centers for Disease Control and Prevention (1992). Principles of Epidemiology, 2 nd ed. Atlanta, GA: Public Health Practice Program Office. Centers for Disease Control and Prevention. Outbreak of Meningococcal Disease Associated with an Elementary School- -Oklahoma, March 2010; MMWR April 6, 2012 / 61(13);217-221. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6113a1.htm? s_cid=mm6113a1_w http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6113a1.htm? s_cid=mm6113a1_w Centers for Disease Control and Prevention. Brainerd Diarrhea. Division of Bacterial Disease; October 2006. http://www.cdc.gov/ncidod/dbmd/diseaseinfo/brainerddiarrhea_ g.htm http://www.cdc.gov/ncidod/dbmd/diseaseinfo/brainerddiarrhea_ g.htm FOCUS Workgroup. An Overview of Outbreak Investigations. FOCUS on Field Epidemiology (1):1. http://cphp.sph.unc.edu/focus/issuelist.htm http://cphp.sph.unc.edu/focus/issuelist.htm

30. References and Resources FOCUS Workgroup. Anatomy and Physiology of an Outbreak Investigation Team. FOCUS on Field Epidemiology (1):2. http://cphp.sph.unc.edu/focus/issuelist.htm http://cphp.sph.unc.edu/focus/issuelist.htm Hall, J.A., et al. Epidemiologic profiling: evaluating foodborne outbreaks for which no pathogen was isolated by routine laboratory testing: United States, 1982-9. Epidemiol Infect. 2001;127:381-7 Nelson, A. Embarking on an Outbreak Investigation. FOCUS on Field Epidemiology (1):3. http://cphp.sph.unc.edu/focus/issuelist.htm http://cphp.sph.unc.edu/focus/issuelist.htm Torok, M. Case Finding and Line Listing: A Guide for Investigators FOCUS on Field Epidemiology (1):4. http://cphp.sph.unc.edu/focus/issuelist.htm http://cphp.sph.unc.edu/focus/issuelist.htm Torok, M. Epidemic Curves. FOCUS on Field Epidemiology (1):5. http://cphp.sph.unc.edu/focus/issuelist.htmhttp://cphp.sph.unc.edu/focus/issuelist.htm

31. Public Health Disaster Planning at District Level 31 The example of your country Epidemics are the commonest Public Health emergency in our districts In Uganda for example, 6 outbreaks occurred in 8 months: Cholera, Meningitis, Hepatitis E, Marburg, Plague and Ebola Can you name 5 outbreaks that have occurred recently in your district? WisGuard Pics, flickr

32. Public Health Disaster Planning at District Level 32 Other Epidemic prone diseases Sexually Transmitted Infections including HIV/AIDS, Syphilis, Gonorrhea etc Plague Hepatitis E Massive chemical poisoning (e.g. poisoning from illicit alcohol

33. Public Health Disaster Planning at District Level 33 Detecting an outbreak: Case Study 1 Let a volunteer read Case Study 1 (Refer to the introductory part of this session in your manual) Questions for brainstorming: –Is this a scenario that could occur in your district? –How did the district authorities establish that there is an outbreak?

34. Public Health Disaster Planning at District Level 34 Detecting an Outbreak Obtain initial notification of the outbreak We receive information about the likelihood of an outbreak from: –The community –Cases coming to health centres –Local leaders –Every rumour must be investigated!

35. Public Health Disaster Planning at District Level 35 Detecting an outbreak There must be a Case Definition for the diseases and it should be known by the health workers at all levels There must be an un-expected rise in new cases of these diseases beyond the expected level

36. Examples of case definitions Take 5 minutes to read the case definitions for the following diseases as attached in the reader marked “Extension Activity 1.2: Standard Case Definitions for some Epidemic Prone Diseases”: –1. Polio –2. Measles –3. Cholera –4. Ebola –5. Bacterial Meningitis NB: Case definitions may be changed according to the locality and the nature of the symptoms.

37. Examples of case definitions The District RRT can develop a working case definition where there is no standard one depending on common symptoms and risk factors Can you suggest a case definition for the following? –An outbreak of sudden alcohol related illness and deaths in zone X –An outbreak of dysentery in camp Y –An outbreak of sudden food-related illness and deaths in a village Z Public Health Disaster Planning at District Level 37

38. Public Health Disaster Planning at District Level 38 Thresholds for detecting an outbreak Some epidemic prone diseases exist in the community even without an outbreak –Outbreaks occur when there is a sharp rise in cases (e.g. Malaria)

39. Public Health Disaster Planning at District Level 39 Thresholds for detecting an outbreak Some epidemic prone diseases do not exist normally in the community –The occurrence of just one confirmed case is considered an outbreak (e.g. Cholera)

40. Public Health Disaster Planning at District Level 40 Thresholds for detecting an outbreak Some epidemic prone diseases are rare and highly deadly when they occur –We do not have to wait for confirmation of a case –Just one suspected case is enough to consider an outbreak (e.g. Ebola)

41. Public Health Disaster Planning at District Level 41 Thresholds for detecting an outbreak Therefore, thresholds differ from disease to disease –Cholera – One confirmed case –Ebola – One suspected case –Measles – A cluster of 5 or more suspected cases OR at least 3 confirmed positive cases in a catchment area of a health facility in a month –Malaria – A sharp seasonal rise in cases beyond the usual number of cases

42. Public Health Disaster Planning at District Level 42 Case Study 2: Let a volunteer read Case Study 2 (Refer to the introductory part of this session in your manual) Questions for general discussion: –How do you think the District and Ministry of Health officials went about investigating the outbreak? –What do you understand by the term ‘early response’

43. Public Health Disaster Planning at District Level 43 Steps in investigating an outbreak In some of your districts, you have responded to outbreaks; think of a recent suspected outbreak that occurred in your district: what steps did you go through to respond to it?

44. Public Health Disaster Planning at District Level 44 Step 1: Initial response and confirmation of outbreak –Assemble team and prepare for an initial field visit as soon as possible –Choose a working case definition and confirm cases –Find cases systematically –Confirm whether there is an outbreak by comparing occurrence of cases with thresholds –Describe who is affected, when and where?

45. Public Health Disaster Planning at District Level 45 Step 2 Identify and manage cases –Establish a district task force and allocate them their responsibilities –Use the working case definition to find cases –Set up a treatment centre

46. Public Health Disaster Planning at District Level 46 Steps 3 Set up immediate control measures –Treat cases to interrupt transmission and reduce deaths –Consider vaccination, disinfection and protective wear –Provide health education to those at risk –Communicate clearly to reduce panic

47. Public Health Disaster Planning at District Level 47 Step 4 Address the resource gaps –Ensure adequate medical supplies and logistics to handle cases –Look for additional resources to address the gaps –Contact Ministry of Health and partner agencies

48. Public Health Disaster Planning at District Level 48 Step 5 Determine responsible factors and make a report –Analyse available information to establish the risk factors –Prepare a report and disseminate it –Recommend and implement priority control measures “The Salmonella probe widens” cartoon removed.

49. Public Health Disaster Planning at District Level 49 Step 6 Surveillance: Be on your guard –Strengthen existing system to be able to find cases actively –Learn from this outbreak to respond better in future –Put in place measures to prevent other outbreaks in future

50. Public Health Disaster Planning at District Level 50 End!

51. Public Health Disaster Planning at District Level Additional Source Information for more information see: http://open.umich.edu/wiki/CitationPolicy Slide 3, Image 4: CDC, "Outbreak Investigation", http://blogs.cdc.gov/publichealthmatters/2011/09/outbreak-investigation-a-cheat-sheet/, Public Domain - Government Slide 7, Image 4: WisGuard Pics, "110518-A-CD688", flickr, http://www.flickr.com/photos/wiguardpics/5737958521/, CC: BY-NC-ND 2.0, http://creativecommons.org/licenses/by-nc-nd/2.0/ Slide 25, Image 4: “The Salmonella probe widens” cartoon removed.