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Diseases in Nature Conference. Disease Outbreak Investigations. Austin, Texas, June 11 th 2007. John Herbold DVM, MPH, PhD, DACVPM, FACE Center for Biosecurity & Public Health Preparedness University of Texas School of Public Health. Disease Outbreak Investigations.

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diseases in nature conference
Diseases in Nature Conference

Disease Outbreak Investigations

Austin, Texas, June 11th 2007

John Herbold DVM, MPH, PhD, DACVPM, FACE

Center for Biosecurity & Public Health Preparedness

University of Texas School of Public Health

slide3

Disease Outbreak Investigations

“...So far this appears to be an isolated case”

CDC Press Release on Florida Anthrax Case

slide5

A ‘Cutting Edge’ Review of

Disease Outbreak Investigation Strategies

outline of the investigation of an epidemic mausner bahn epidemiology an introductory text 1985
OUTLINE OF THE INVESTIGATION OF AN EPIDEMICMausner & Bahn, Epidemiology An Introductory Text, 1985

...an exciting exercise in medical detection

...painstaking accumulation of data

in the field

...careful analysis of data

...flashes of insight

...systematic outline

mausner bahn outline
Mausner & Bahn Outline
  • Preliminary Analysis
  • Verify the Diagnosis
  • Verify the Existence of an epidemic
  • Describe the Epidemic by PPT
  • Formulate and Test Hypotheses
mausner bahn outline8
Mausner & Bahn Outline
  • Possible Further Investigation and Analysis
  • Search for Additional Cases
  • Analyze the Data
  • Make a Decision [Hypotheses Considered]
  • Intervention and Follow-up
mausner bahn outline9
Mausner & Bahn Outline
  • Report of the Investigation
  • include discussion of factors
  • evaluation of measures used for control
  • recommendations for prevention
strategy to investigate the etiology of disease

‘strategy’ to investigate the etiology of disease

I. Confirm the existence of a health problem

A. Define cases in terms of person, place, and time

B. Describe what you see..............

C. Discuss explanations for associations that you see

II. Discuss possible causes, etiology, of the problem

A. Assess information, literature, consult specialists

B. Generate possible/potential hypotheses....

C. Display ('examine') the evidence (information)

III. Test specific hypothesis (ses)

IV. Action (intervention, prevention, clinical trial)

V. Experimental (laboratory, animal models, etc.)

VI. Review I through V and develop unifying theory

VII. Publish a report ... present in a public forum

VIII. Re-confirm (that's why its called re-search)

Reference: Roht et al,

ten steps for investigating an epidemic

“Ten” Steps For Investigating An Epidemic

Prepare for field work (re – search the literature; talk to experts)

Establish the existence of an outbreak (endemic, epidemic, cluster, outbreak)

Verify the diagnosis (clinical, laboratory, epidemiologic)

Define and identify cases

Establish a case definition

Identify and count cases

Perform descriptive epidemiology (person, place, time)

Develop hypotheses

Evaluate Hypotheses

Reconsider/refine hypotheses and execute additional studies

Implement control and prevention measures

Communicate findings

Reference: CDC Satellite Broadcast Course, 1993

time to get to work13
Time to get to work !!!
  • Late Friday afternoon... Of course
  • Phone Call to LHD from Local Physician
  • Looks like hepatitis...
    • 1 adult patient who also tells Doc...
      • 2 colleagues at work (law office downtown)
      • Diagnosed this week also...

What first steps should be taken???

slide14

What first steps should be taken???

  • Read up on hepatitis
  • Exact dates of onset
  • Interview 3 cases (travel hx)
  • Line listing of patients (demographics)
  • Interview co-workers (jobs, restaurants, social)
  • What’s community experience with hepatitis
  • Extent of outbreak outside law office
  • Number of cases over past year
  • Anything else??
slide16

Know ..

3 cases of hepatitis A within the week

Hx of only 12 cases last year

Anytown USA

What would you use for a case definition ?

What would you do next ?

slide17

Know ..

3 cases of hepatitis A within the week

Hx of only 12 cases last year

Anytown USA

What would you use for a case definition ?

  • Clinical & Laboratory parameters
      • (Person)
  • 3 cases date of onset plus/minus 3 days
      • (Time)
  • People in Law Office
      • (Place)
slide18

Know ..

3 cases of hepatitis A within the week

Hx of only 12 cases last year

Anytown USA

What would you do next ?

  • Expand search for cases
      • (law firm and family members)
  • Look @ community experience
      • (labs, hospital, cases past month)
  • Other suggestions.....
  • This looks like a ‘lot of work’ !
slide20

Know ..

32 cases of hepatitis A within the week

Not confined to law office

Live all over the county

  • What type of outbreak is this?
    • point source
    • continuing common source
    • person to person
  • What do you think caused it?
  • How would you check your hypothesis?
slide21

Know ..

32 cases of hepatitis A within the week

Not confined to law office

Live all over the county

  • What type of outbreak is this?
    • point source (time/place cluster)

... food .... water

    • continuing common source (#’s)

... water

    • person to person (incubation period)
slide22

Know ..

32 cases of hepatitis A within the week

Not confined to law office

Live all over the county

  • What do you think caused it?
    • Food
    • Water
    • Other ?
slide23

Know ..

32 cases of hepatitis A within the week

Not confined to law office

Live all over the county

How would you check your hypothesis?

  • Municipal water system records
  • Food histories of patients
  • Other ?
slide25

Know ..

32 cases of hepatitis A within the week

Not confined to law office

Live all over the county

Most likely foodborne

How would you design studies to evaluate various foodborne routes?

What foods would you suspect and why?

slide26

Know ..

32 cases of hepatitis A within the week

Not confined to law office

Live all over the county

Most likely foodborne

  • How would you design studies to evaluate various foodborne routes?
    • Cases and co-workers as controls
    • Where & how often did you eat downtown
    • Food preferences
slide27

Know ..

32 cases of hepatitis A within the week

Not confined to law office

Live all over the county

Most likely foodborne

  • What foods would you suspect and why?
      • Salads
      • Fresh fruits
      • Uncooked vegetables
      • Seafood (raw)
      • Pizza ?
louisville ky 1988
Louisville KY 1988
  • more than 200 cases confirmed
  • immune globulin given to contacts
  • 13% of cases hospitalized !
  • little secondary spread
  • no children “Adult Outbreak”
slide30
Reginald Finger MD,MPH

KY State Epidemiologist

Melodious Voice

Mark Garmack

UAB SPH

PRODUCED BY

Alabama Department of Health

Principles of Epidemiology By Satellite

May 20th 1993

slide32

One World

One Medicine

One Ecology