1. Overview of Outbreak Investigations

2. Goals The goals of this presentation are to: Provide a general overview of the basic steps of disease outbreak investigations Describe factors that may contribute to a decision to investigate

3. Outbreaks: The basics Goals of an outbreak investigation: To identify the source of illness To guide public health intervention Ways to recognize an outbreak: Routine surveillance activities Reports from clinicians and laboratories Reports from affected individuals

4. Why investigate an outbreak? Characterize a public health problem Identify preventable risk factors Provide new research insights into disease Train health department staff in methods of public health investigations and emergency response

5. Steps of an outbreak investigation 1. Verify the diagnosis and confirm the outbreak 2. Define a case and conduct case finding 3. Tabulate and orient data: time, place, person 4. Take immediate control measures

6. Steps of an outbreak investigation 5. Formulate and test hypothesis 6. Plan and execute additional studies 7. Implement and evaluate control measures 8. Communicate findings

7. Steps of an outbreak investigation These steps may occur simultaneously or be repeated as new information is received.

8. Verify the diagnosis and confirm the outbreak Confirm laboratory testing Rule out misdiagnoses or laboratory error

9. Define a case and conduct case finding Develop a specific case definition using: Symptoms or laboratory results Time period Location Conduct surveillance using case definition Existing surveillance Active surveillance (e.g. review medical records) Interview case-patients

10. Tabulate and orient data Create line listing Person Who was infected? What do the cases have in common? Place Where were they infected? May be useful to draw a map Time When were they infected? Create an epidemic curve

11. Take immediate control measures If an obvious source of the contamination is identified…institute control measures immediately!

12. Formulate and test hypothesis Develop hypotheses literature reviews of previous outbreaks interviews of several case-patients Conduct an analytic study to test hypotheses Retrospective cohort study Case-control study

13. Plan and execute additional studies Environmental sampling Collect appropriate samples Allow epidemiological data to guide testing If analytic study results are conclusive, don’t wait for positive samples before implementing prevention

14. Implement and evaluate control measures Prevent further exposure and future outbreaks by eliminating or treating the source Work with regulators, industry, and health educators to institute measures Create mechanism to evaluate both short- and long-term success

15. Communicate findings Identify a single member of the investigation team to interact with media and communicate progress and findings Summarize investigation, make recommendations, and disseminate report to all participants

16. Conclusions The steps listed for an outbreak investigation comprise a brief introduction and rough guide. Only by conducting investigations repeatedly over an entire career will public health professionals truly learn the methods of outbreak investigations. Snow’s “shoe leather epidemiology” serves as a model of critical thinking and public health action.

17. Online resources Information for Public Health Professionals- Investigating Foodborne Disease Outbreaks. Available online at: http://www.cdc.gov/foodborneoutbreaks/info_healthprofessiona l.htm To conduct an online outbreak investigation, “Botulism in Argentina,” visit the CDC website at: http://www.phppo.cdc.gov/phtn/casestudies/ computerbased/default.htm To explore an historical outbreak investigation, visit the online UNC John Snow Case Study at: http://www.sph.unc.edu/courses/Course_support/ Case_studies/John Snow

18. References Michael Gregg. Field Epidemiology. 2nd edition. Oxford University Press, 2002. Control of Communicable Disease in Man, 17th edition. Chin, J (ed). APHA, 2000. Principles & Practice of Infectious Diseases, 5th edition. Mandell GL, Bennett JE, Dolin R (eds). Churchill Livingstone; 2000