Outbreak Investigation

on HAI’s

Andaru Dahesihdewi
Clinical Epidemiology & Biostatistic Unit
Email- adahesihdewi@yahoo.com
 Learning Objectives
1. Developing the basic concept in
investigating an epidemic,
2. To orient toward the art and
science of outbreak investigation
and epidemiology
3. Outbreak investigation on HAI’s
 Definitions
Outbreak

Sudden occurrence of an epidemic

in relatively limited geographic
area.
While an outbreak is usually limited
to a small focal area, an epidemic
covers larger geographical areas
& has more than one focal point.
 Definitions
Outbreak Epidemiology

Study of a disease cluster or

epidemic in order to control or
prevent further spread of the
disease in the population.
 Definitions
Outbreak of HAI’s
 Infection occured > 2x normal prediction

(TRESHOLD)

 Significantly increasing (p<0,05) on infection level

compare with the level before
 HAI’s
• Infection not presented/incubated within 48
hours of hospital admission
• Infection manfests after hospitalised within
certain time (SSI : 30 days or 1 year if with
implant). Readmission criteria can be
included or not.
• Baby delivered with infection within 48
hours (not placental transmitted diseases) by
mother without infection at admission
OUTBREAK Identification & Investigation
of HAI’s

 Must rapidly act  source of problem

 >< spreading

 REPORTING FLOW

SURVEILLANS DATA
MUST BE GOOD, VALID, CONTINUE

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Objectives of Outbreak Investigation

1. Primary - to control the spread of

disease
2. To determine the causes of disease,
its source & mode of transmission
3. To determine who is at risk
4. To determine what exposures
predispose to disease
5. To know magnitude of the problem
 Objectives continued….

6. To identify new agent

7. To determine the effectiveness of
control measures
8. To identify methods for present &
future prevention & control
9. Research & training opportunities
10. Public, Political and legal concerns
The pace & commitment
of OI

Don’t leave the field

without
final results & recommendations
 Trigger events
& Warning Signals

1. Clustering of cases/deaths in
time/space
2. Unusual increase in cases/deaths
3. Shift in age distribution of cases
4. High vector density
 Trigger events & Warning Signals

5. Severe dehydration following

diarrhea in patients above 5 years
age
6. Unusual isolate
 What kinds of information
should be investigated
1. Dx confirmation (lab, ro, etc)
2. Constitute rapid response teams
a. Trained medical & other health personnel
b. Other institution who has responsibility
3. Developing case definition
a. Based on sign, symptom, agent causal
b. Involving person, place, time
4. A list of laboratories’ results
5. A List of “high risk” pockets
 What kinds of information
should be investigated

6. Strengthen routine surveillance system &

use the data to develop hypotheses
a. 5W 1 H
b. age, sex, time, duration, place,
exposure
7. Infection rate  verivy the outbreak
 Preparedness

1. Establish rapid communication network

2. Ensure availability of essential supplies
3. Setup inter-departmental committees
- Check initial information

Initial information on an outbreak

The regional health coordinator must

determine

 the information is correct

 – Formulate a plan of
action

- based on situational analysis

- technical, economical, political factors
– Prepare for field work

- Identify the team members

- Assign responsibilities.
 Composition of typical field team
Specialists Auxillaries
1. Epidemilogist 1. Nurses
2. Clinician (pathologist) 2. Specialist assistants
3. Microbiologist 3. Secretary/Interpreter
4. Veterinarian 4. Driver
5. Entomologist
6. Mammalogist
7. Sanitary engineer
8. Toxicologist
9. Information Specialist
 – Confirm the existence
Are there cases in excess of the
baseline rate for that disease & setting?
The excess frequency  found out with
Epidemic Threshold Curve.
The periodic frequency for previous
3 years is plotted on a graph. Another
graph at mean + 2SD level is
superimposed on it. Any fluctuations
beyond these 2 graphs should be
treated as epidemic fluctuations 
method of moving averages
Moving averages

Epidemic treshold curve

 Explain demographic factors
• Risk factors ?
– invasive procedure
– surgical
– underlying disease

Laboratory result : culture & sesitivity test

Agent, source, transmission

pathway
Search for the source of infection
• to eliminate, terminate, isolate the
source.
• identify the time of disease onset,
ascertain the range of incubation
periods & look for the source in time
interval between the maximum & the
minimum IPs.
• outbreaks person to person
transmission  search all the contacts
of the index case (contact tracing).
 – Compile & Orient data
(a) Time : The epi-curve gives the
magnitude of outbreak, its mode of
spread & the possible duration of the
epidemic  The unit of time on X-
axis are smaller than the expected
incubation period of the disease.
(b) Place :  major clues regarding the
source of agent and/or nature of
exposure. Spot maps show a pattern
of distribution of cases.
 Step 8 – Compile & Orient data

(c) Person:
• age, sex, race, occupation
• virtually any other character 
portraying the uniqueness of case
population.
 – Choose a Study Design

• Case-control, cohort, case cohort is

chosen based on
• size & availability of the exposed population
• the speed with which the results are needed
• the available resources.

• dictate the appropriate analysis &

hypothesis testing.
 – Perform Lab Analysis
• Collecting & testing appropriate
specimens : properly time
• To identify the etiologic agent
• Examples of specimens :
• food & water, environmental samples (air
settling plates), clinical (blood, stool,
sputum or wound)
• samples from cases & controls.
Environmental Investigation

A study of environmental conditions,

the dynamics interaction - the
population & etiologic agents

formulate the hypothesis

the genesis of the epidemic

Assist in answering How? And Why?

 Important points
1. Rare disease assumption: The OR &
RR approximate each other if the attack
rates is less than 5% but the attack rates
are much higher in outbreaks.
2. To correct for multiple comparisons, the
most effective approach is to lower the p-
value according to the number of
comparisons made.
 Control measures

• Depend upon knowledge of

• etiologic agent,
• mode of transmission
• other contributing factors.

• Protective measures
• for patients (isolation & disinfection)
• their contacts (quarantine)
• the community (immunization, etc).
 – Additional studies

May be a need to find more

patients, to define better the
extent of the epidemic, a new lab
method or case finding method
may need to be evaluated 
perform more detailed & carefully
executed studies.
 – Prepare Written Report

• to prepare a written report to

document the investigations, findings
and the recommendations.
• should be submitted, in a
standardized format, to the public
health authorities including the ministry
of health & remain confidential until it
has been given official permission.
 – Communicate findings
• Communicating the investigative findings
clearly is essential.
• All public health officers will benefit if the
experience acquired by the investigative
team is shared by the publication of an
account of the outbreak. As a rule, the
epidemiologist informs those who reported
the first cases of the epidemic first.
 – Post-outbreak Measures
The efficacy of control measures should
be assessed day by day during the
outbreak, a final assessment being made
after it has ended.
This will provide a logical basis for post-
epidemic surveillance & preventive
measures aimed at avoiding the
repetition of similar outbreaks.
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