Outbreak Investigation Manual Final

DISEASE OUTBREAK INVESTIGATION
&
CONTROL MANUAL
Printed in Bhutan
Copyright 2015 Department of Public Health
Cover design by:

Karchung Tshering & Govinda Ghimeray
Contents
Acknowledgment................................................................................................. iii
Foreword.............................................................................................................. iv
Abbreviation......................................................................................................... v
Glossary............................................................................................................... vi
Introduction.......................................................................................................... ix
Objectives............................................................................................................ ix
Chapter I ............................................................................................................. 1
OPERATIONAL STRUCTURE........................................................................ 1
Chapter II............................................................................................................. 3
RAPID RESPONSE TEAMS........................................................................... 3
2.1. National Health Rapid Response Team (NHRRT)................................... 3
2.2. Dzongkhag Health Rapid Response Team (DHRRT).............................. 4
Chapter III............................................................................................................ 7
OUTBREAK INVESTIGATION........................................................................ 7
What is an outbreak?...................................................................................... 7
Definition of Excess of normal expectancy................................................... 7
Reasons for investigating an outbreak............................................................ 7
Overview of Outbreak Investigation Steps...................................................... 7
Step 1: Preparation for field work................................................................... 8
Step 2: Confirm outbreak and diagnosis ........................................................... 8
Step 3: Define case and start case finding ....................................................... 10
IStep 4: Describe the outbreak .......................................................................... 13
Step 5: Develop Hypotheses.............................................................................. 14
Step 6: Test Hypotheses..................................................................................... 15
Step 7: Refine Hypotheses and carry out additional studies:............................. 15
7.1. Laboratory Investigation:...................................................................... 16
i
7.2. Environmental Investigation................................................................. 16
Step 8: Implement control and prevention measures........................................ 17
Step 9: Communicate Findings......................................................................... 17
Step 10: Follow-up of implementation of control measures.............................. 18
Chapter IV................................................................................................................ 21
COMMUNICATION DURING OUTBREAK INVESTIGATION.......................... 21
Annexure 1............................................................................................................... 24
Specific roles and responsibilities:.................................................................... 24
Annexure 2............................................................................................................... 26
Outbreak line listing form:.................................................................................. 26
Annexure 3............................................................................................................... 27
Rapid Response Kit:......................................................................................... 27
Anexure 4................................................................................................................. 28
Example on how to draw epidemic curve:......................................................... 28
Annexure 5............................................................................................................... 31
Analytic studies: Cohort and Case control........................................................ 31
Annexure 6.............................................................................................................. 36
Collection of clinical samples based on suspected disease.............................. 36
Annexure 7............................................................................................................... 47
Example of prevention and control measures .................................................. 47
Annexure 8............................................................................................................... 49
Annexure 9............................................................................................................... 51
CONTRIBUTORS................................................................................................ 51
ii
Acknowledgment
Department of Public Health is very much indebted to Center for Disease Control, Atlanta, USA
for their funding support in developing and printing of this manual.
Sincere thanks to the contributors of the manual for their invaluable inputs in shaping this
document. We would like to thank all the participants of the outbreak investigation and control
manual development workshop held at Paro in August 2014 for their effort and contribution in
bringing up the first draft of this document.
Furthermore, we would also like to acknowledge PHL with much appreciation for the final
compilation and Avian Influenza Program for coordinating in developing and printing of this
manual.
Lastly, we would like to acknowledge the adoption and referencing from Guidelines for the
Investigation and Control of disease outbreaks of ESRI-New Zealand in bringing up this manual.
iii
Foreword
The Disease Outbreak Investigation & Control Manual is the first version developed by
Department of Public Health to provide comprehensive guide for outbreak investigation and
management. Outbreak Investigation was included as one of the chapters in the 2nd Edition of
Operational manual on the National Notifiable Diseases Surveillance guideline which covered
only the basic outbreak investigation steps.
The key inclusion in this manual is the operational structure of outbreak information flow, command
and composition of health rapid response team at district and national level with clear line of role
and responsibilities during the outbreak investigation and management. The manual is developed
in line with National Early Warning Alert and Response Surveillance Guideline (NEWARS) and
Health Emergency Contingency Plan. The manual also describes step-by-step guide for outbreak
investigation which are standard steps followed for any outbreak investigation.
We hope that the manual will be useful to all health personnel in the field to investigate outbreaks
scientifically and provide timely control measures. Since this is the first edition of the manual, we
would like to welcome suggestions and recommendations from all users regarding operational
issues during implementation so as to further improve this manual.
(Dr. Pandup Tshering)

DIRECTOR
Department of Public Health
iv
Abbreviation
ADM Administrative
BAFRA Bhutan Agriculture & Food Regulatory Authority
BHU Basic Health Unit
CDC Center for Disease Control
CMO Chief Medical Officer
CPO Chief Program Officer
DDM Department of Disaster Management
DG Director General
DHO District Health Officer
DHRRT District Health Rapid Response Team
DoL Department of Livestock
DoPH Department of Public Health
EMS Emergency Medical Services
FETP Field Epidemiology Training Program
GIS Global Information System
HCDD Health Care & Diagnostic Division
HECP Health Emergency Contingency Plan
HEOC Health Emergency Operation Centre
IHR International Health Regulation
MoH Ministry of Health
MoHCA Ministry of Home & Culture Affairs
MRSA Methicillin resistant Staphylococcus aureus
NCAH National Center for Animal Health
NDMA National Disaster Management Authority
NEWARS National Early Warning Alert and Response
Surveillance Guideline
NHRRT National Health Rapid Response Team
NICC National Incident Command Center
PHL Public Health Laboratory
PPE Personal Protective Equipments
RRT Rapid Response Team
SOP Standard operating Procedure
STIs Sexually transmitted infections
WHO World Health Organization
v
Glossary
Attack Rate: A type of cumulative incidence rate which expresses the occurrence of a disease
among a specific population at risk observed for a limited period of time, often due to a very
specific exposure.
Carrier: A person or animal that harbors a specific infectious agent, is asymptomatic, and is a
potential source of infection for man or animals.
Case: a person with a specific disease.
Case-control study: A type of observational analytic study. Enrollment into the study is based on
presence (case) or absence (control) of disease. Characteristics such as previous exposures
are then compared between cases and controls.
Case definition: A set of criteria used for investigative purposes to decide whether a person
has a particular disease or whether a person is to be included in a case category by specifying
clinical and laboratory criteria and by specifying limitations on time, place and person.
Case finding: The process of identifying all possible cases; this typically uses a broad case
definition and occurs early in the investigation. Later in the investigation, case finding might be
performed to assess the extent of the outbreak.
Cluster: a group of people with the same disease in the same place and at the same time.
Cohort study: A type of observational analytic study. Enrollment in the study is based on exposure
characteristics or membership in a group. Disease, death of other health-related outcomes are
then ascertained and compared.
Common source outbreak: An outbreak that results from a group of persons being exposed to
an infectious agent or toxin from a single source.
Confirmed case: a case with laboratory identified etiology
Contact: exposure to a source of an infection, or a person so exposed
Controls: Subject with whom comparison is made in a case-control study or other type of
epidemiologic study. Selection of appropriate controls is crucial to the validity of epidemiologic
studies.
Epidemic: The occurrence of more cases of disease than expected in a given area or among a
specific group of people during a particular period of time.
Epidemic curve (Epi curve): A histogram plotting the distribution of cases by time of onset. Epi
curves help characterize an outbreak and give clues about the source of the outbreak (e.g., point
source vs. on-going outbreaks).
Epidemiology: The study of the distribution and determinants of health-related states or events
in specified populations, and the application of this study to the control of health problems.
Food-borne outbreak (FBO): A FBO is the occurrence of two or more cases of a similar illness
resulting from the ingestion of a common food. (Before 1992, only one case of botulism or marine
or chemical intoxication was required to constitute a FBO. Since 1992, two or more cases are now
required for these diseases to be defined as an outbreak.)
vi
High-risk group: A group in the community with an elevated risk for a particular disease.
Host: A person or other living organism that can be infected by an infectious agent under natural
conditions.
Host factors: An intrinsic factor (e.g., age, sex, race, behaviors) which influences an individuals
exposure, susceptibility, or response to a causative agent.
Incidence rate: The measure of frequency of new cases of a particular disease in a population
during a specified period of time.
Incubation period: The period of time between exposure to an infectious agent and the onset of
signs and symptoms of disease.
Index case: The first case among a number of similar cases that are epidemiologically related.
Line list: a table listing case names age sex residence symptoms employment etc. which will help
us to compare many characteristics for possible similarities or associations.
Morbidity: any deviation from physiological or psychological well-being.
Onset: The time the first clinical signs or symptoms begin to occur.
Outbreak: Same as epidemic. Often the preferred word as it may avoid the sensationalism
associated with the word epidemic.
Outbreak settings:
i. Common event: An outbreak due to exposure of a group of persons to a harmful influence
that is common to the individuals in the group, where the exposure is brief and essentially
simultaneous and all resultant cases develop within one incubation period of the disease.
Cases have exposures that occur at virtually the same place and time. Examples:
religious gatherings, weddings, sports events, conferences or any other event that occurs
within a specified time period.
ii. Dispersed common source: Outbreaks due to exposure of a group of persons in a community
to a harmful influence that is common to the individuals in the group, where exposures
have not all occurred around the same place or necessarily around the same time.
These outbreaks are often due to the consumption of a widely distributed vehicle of infection
transmission, such as a contaminated food product or drinking-water.
iii. Common source in a specific place (or site): Outbreaks due to the exposure of a group
of persons in a community to a harmful influence that is common to the individuals in the
group, and where all the exposures have occurred at the same place, but not at the same
time. Examples include those where exposures have occurred within the setting of a single
swimming pool, restaurant, workplace or farm.
iv. Community-wide: An outbreak affecting individuals in a community, where transmission
predominantly occurs by direct exposure of susceptible people to infectious people.
Examples include an outbreak of hepatitis A within an immigrant community, an outbreak of
tuberculosis, and outbreak of measles.
v. Institutional: An outbreak confined to the population of a specific residential or other
institutional setting, such as a hospital, hotels, religious institutes, prison or boarding school.
vii
vi. Household: An outbreak confined to members of a single household.
Pandemic: an epidemic that affects several countries and sometimes affects the world.
Point source outbreak: Outbreak due to exposure of a group of persons to an infectious agent
common to the individuals in the group.
Prevalence: The number or proportion of cases or events or conditions in a given population.
Prevalence rate: The measure of frequency of all current cases of a particular disease, regardless
of the time of onset, within a particular population either at a specified instant or during a specified
period of time.
Probable case: A case without laboratory confirmation that has typical clinical features of the
particular disease under investigation without laboratory confirmation.
Questionnaire: Predetermined set of questions used to collect data.
Recreational water: Waters used for swimming, whirlpools, hot tubs, spas and water parks; it
may also include naturally occurring fresh and marine surface waters.
Reservoir: The habitat or organisms in which an infectious agent normally lives, grows and
multiplies.
Serotype: subdivision of a species or subspecies that is distinguishable from other strain based
on their antigenic variations.
Surveillance: The detection of health problems through the appropriate collection of data,
followed by its collation, analysis, interpretation, and dissemination.
Susceptible: A person lacking sufficient resistance to a particular disease agent to prevent
disease if or when exposed.
Vehicle: An inanimate intermediary in the indirect transmission of an agent that carries the agent
from a reservoir to a susceptible host.
Virulence: The degree of pathogenicity of an infectious agent.
Waterborne outbreak: Two criteria required: (1) two or more people experience a similar illness
after the ingestion of drinking water or after exposure to water used for recreational purposes,
and (2) epidemiologic evidence must implicate water as the probable source of the illness. (The
requirement for two or more is waived for single cases of laboratory-confirmed primary amebic
meningo-encephalitis and for single cases of chemical poisoning if the water-quality data indicate
contamination by the chemical.)
Zoonosis: An infection or an infectious disease transmissible under natural conditions between
animals and man.
viii
Introduction
Disease outbreak can cause significant morbidity and mortality, adverse socio-economic impact,
and requires enormous resources to manage them effectively. Investigation of an outbreak is
of urgent public health importance and requires immediate reporting to the concerned health
authorities. The ability to manage disease outbreaks effectively is a key responsibility of public
health service. Rapid detection, prompt reporting, and rapid response system is essential for
effective disease prevention and control to minimize its impact.
Several key questions need to be addressed to determine the time and place of occurrence of
an event, the extent of illness and population affected; type of exposure and possible mode of
transmission, and most effective control measures. It is crucial to have a clearly defined disease
outbreak investigation and response system, outlining roles and responsibilities of different
stakeholders involved for effective diseases prevention and management. As effective disease
outbreak investigation and control measures require involvement of multi-disciplinary team, this
manual provides a structure and mechanism for coordinating activities among various public
health institutions, laboratories and other relevant agencies.
Scope of the manual

This manual is intended for use by health officials at all levels engaged in disease outbreak
investigation and response. This manual is developed to outline detail outbreak investigation
and response components of the Health Emergency Contingency Plan (HECP). This manual
covers outbreak investigation and response system for all communicable and non-communicable
diseases that are of national, regional, and international concerns.
Objectives
The objectives of this manual are:
To strengthen the effectiveness and efficiency of disease outbreak investigation and management.
To describe systematic and scientific diseases outbreak investigation and response procedures.
To provide ready reference to health officials for disease outbreak investigation and management.
ix
Disease Outbreak Investigation & Control Manual
Chapter I
OPERATIONAL STRUCTURE
The organizational structure for disease outbreak investigation and response system is developed
in consistence with HECP, National Early Warning Alert and Response Surveillance Guideline
(NEWARS), National Influenza Pandemic Preparedness Plan (NIPPP), and Disaster Management
Act of Bhutan, 2013. The overall structure for the disease outbreak investigation and control
system is provided in Figure 1. The green box shows the components of the disease reporting
and notification system, whereas the orange box shows the components of flow of command for
disease outbreak investigation and control measures.
The disease information collation, reporting, and notification system within the health sector is
described in NEWARS. In addition, information and reports related to zoonotic and foodborne
diseases will be shared by the National Centre for Animal Health (NCAH) and Bhutan Agriculture
and Food Regulatory Authority (BAFRA), respectively. Information of disease outbreaks of IHR
importance will be shared by WHO through the National Focal Point for International Health
Regulation (NFP-IHR).
This structure outlines the notification and response system for all outbreaks of infectious and
non-communicable diseases (e.g. outbreaks of nutritional deficiency, toxicity and poisoning
due to mushrooms, chemicals and heavy metals, etc.). In case of pandemic or large-scale
disease outbreaks in the country, this structure should be followed in conjunction with HECP,
NIPPP, and Disaster Management Act of Bhutan 2013. In a phase of natural disaster notified by
National Disaster Management Authority (NDMA) or Department of Disaster Management (DDM)
requiring medical care (not related to disease outbreak), the Emergency Medical Service (EMS)
will activate Health Emergency Operation Centre (HEOC) and National Health Rapid Response
Team (NHRRT) (arrow (a) of Figure 1). This may or not require an activation of other teams
of NHRRT. In case of pandemics and large-scale outbreaks, the EMS will activate HEOC and
NHRRT.
For clarity and simplicity, in case of non-pandemic disease outbreaks, a reduced form of the
disease outbreak investigation and response system is provided in Figure 2. In case of other than
pandemics and large-scale outbreaks beyond the coping capacity of a Dzongkhag, the NHRRT
will be activated by DoPH (arrow (c) of Figure 2).
In case of localized disease outbreaks within a district and those outbreaks that can be managed
by district, a District Health Office (DHO) shall activate the District Health Rapid Response Team
(DHRRT) (arrow (e) of Figure 2). This activation can be done either based on the advice of
DoPH (with information from NEWAR managed by Public Health Laboratory (PHL)) (arrow (d) of
Figure 2); or a DHO itself can initiate this activation based on the information from health centers
(arrow (e) of Figure 2). The District Outbreak Investigation Team (DOIT) will carry out preliminary
investigation and provide assessment as to whether the outbreak can be managed by the DHRRT
or require the activation of HEOC or NHRRT. If activation of HEOC or NHRRT is required, the
DHO shall inform the DoPH which in turn will inform HLC/NICC, following which the HEOC or
NHRRRT will be activated.
1
The composition of teams of NHRRT and DHRRT, and composition of members of different teams
including their Terms of Reference (ToR) and functions are outlined in the subsequent sections
(Chapter III). In case of zoonotic and foodborne disease outbreaks, the outbreak investigation and
response shall be implemented jointly with Department of Livestock (DoL) and Bhutan Agriculture
and Food Regulatory Authority (BAFRA). If law and order support is necessary the Royal Bhutan
Police shall be involved.
Outbreak notification flow Outbreak command flow
NDMA/DDM
a NDMA/DDM
HLC/NICC (MOH) EMS
NEMT
a b
TAC HLC/NICC (MOH) EMS NOIT
NEMT
b Other stakeholders
c NHRRT Logistic Team (DOL/BAFRA/RBP)
WHO NFP- TAC DOPH NOIT
IHR NHRRT LawLogistic
& order Other stakeholders
d c Team (DOL/BAFRA/RBP)
WHO NFP- DOPH
INFOSAN/BAFRA IHR DHO Comm.
LawTeam
& order
d
PHL Comm. Team
NCAH/DOL
INFOSAN/BAFRA DHO DOIT
e
PHL DEMT
NCAH/DOL DOIT
e DHRRT Other stakeholders
Logistic Team (DOL/BAFRA/RBP)
DEMT
LawLogistic
& order Other stakeholders
DHRRT Team (DOL/BAFRA/RBP)
Other sources Hospitals/BHUs Regional/National
Referral Hospitals Comm. LawTeam
& order
a) In case of natural disaster like flood, earthquake, Referral NDMA = National Disaster Management Authority; HLC=High-level Committee Comm.
Hospitals of MinistryTeam
of Health
fire accident, other accidents. NICC= National Incident Command Centre; MoH = Ministry of Health; TAC=Technical Advisory Committee; DoPH=Department of Public Health;
b) Pandemic diseases (pandemic influenza, Ebola, etc.). PHL=Public Health Lab; NFP-IHR=National Focal Point -International Health Regulation; WHO=World Health Organization; BHUs=Basic Health
c) Epidemic infectious
a) In case of naturalanddisaster
non-infectious diseases
like flood, excluding (b).
earthquake, Units;NDMA
DHO == District
NationalHealth Office;
Disaster Management Authority; HLC=High-level Committee of Ministry of Health
d and e)fire
District level other
accident, outbreak of infectious and non-infectious.
accidents. NHRRT= National
NICC= NationalHealth Rapid
Incident ResponseCentre;
Command Team; MoH
NOIT== National
Ministry Outbreak
of Health;Investigation
TAC=TechnicalTeam; NEMT=National
Advisory Committee;Emergency Medical Team;
DoPH=Department of Public Health;
Legendb) Pandemic diseases (pandemic influenza, Ebola, etc.). DHRRT=District
PHL=PublicHealth
HealthRapid Response Team; Focal Point -International Health Regulation; WHO=World Health Organization; BHUs=Basic Health
Lab; NFP-IHR=National
Black arrow show disease information sharing
c) Epidemic infectious and non-infectious diseases and reporting system
excluding (b). DOIT=Units;
District Outbreak Investigation
DHO = District Health Office; Team; DEMT=District Emergency Medical Team;
Red d andarrow show outbreak
e) District investigation
level outbreak and response
of infectious command system
and non-infectious. NCAH=National CentreHealth
NHRRT= National for Animal
RapidHealth; DOL=Department
Response of Livestock
Team; NOIT= National Outbreak Investigation Team; NEMT=National Emergency Medical Team;
Legend INFOSAN=International
DHRRT=District Health FoodRapid
Safety Authorities
Response Network; BAFRA=Bhutan Agriculture and Food Regulatory Authority
Team;
Black arrow show disease information sharing and reporting system RBP=Royal
DOIT=Bhutan
District Police
Outbreak Investigation Team; DEMT=District Emergency Medical Team;
Red arrow show outbreak investigation and response command system NCAH=National Centre for Animal Health; DOL=Department of Livestock
INFOSAN=International Food Safety Authorities Network; BAFRA=Bhutan Agriculture and Food Regulatory Authority
RBP=Royal Bhutan Police
Figure 1: Flow chart representing the overall disease notification and command system for disease outbreak investigation and response including natural
disasters.
Figure 1: Flow chart representing the overall disease notification and command system for disease outbreak investigation and response including natural
disasters.
WHO
NOIT
NCAH/DOL
NFP-IHR NEMT
Other stakeholders
c NHRRT Logistic Team (DOL/BAFRA/RBP)
INFOSAN-
BAFRA
DOPH Law & Order
d Comm. Team
DHO
PHL DOIT
e DEMT
Other stakeholders
DHRRT Logistic Team (DOL/BAFRA/RBP)
Law & Order

Referral Hospitals Comm. Team
c) Epidemic infectious and non-infectious diseases excluding Pandemic diseases (pandemic WHO=World Health Organization; NFP-IHR=National Focal Point -International Health Regulation
influenza, Ebola, etc.). DOPH=Department of Public Health; PHL=Public Health Lab;
d) and e) District level outbreak of infectious and non-infectious. BHUs=Basic Health Units; NCAH=National Centre for Animal Health;
Legend DOL=Department of Livestock; INFOSAN=International Food Safety Authorities Network
Black arrow show disease information sharing and reporting system BAFRA=Bhutan Agriculture and Food Regulatory Authority; DHO = District Health Office;
Red arrow show outbreak investigation and response command system NHRRT= National Health Rapid Response Team; DHRRT=District Health Rapid Response Team; NOIT= National Outbreak
Investigation Team; NEMT=National Emergency Medical Team;
DOIT= District Outbreak Investigation Team; DEMT=District Emergency Medical Team;
RBP=Royal Bhutan Police
Figure 2: Flow chart representing the overall disease notification and command system for disease outbreak investigation and response system.
2
Chapter II
RAPID RESPONSE TEAMS
Following directives from HEOC/DoPH Rapid Response Team should be formed at National
and Dzongkhag levels as per the requirement to undertake disease investigation and response
measures.
Definition of Rapid Response Team (RRT)

A RRT is a predetermined team identified based on individual expertise, experience, and
assembled by matching expertise and incident needs in order to provide rapid response in
managing disease outbreak effectively.
2.1. National Health Rapid Response Team (NHRRT)

The NHRRT team should have capacity to carry out a detailed outbreak investigation, conduct
rapid clinical assessment and recommend/ provide some immediate relief measures. A member
of the team will be the communication manager and through him all communications will be made
by the team. The team also has personnel from the affected district (DHO/ADHO) in the team to
manage the day to day logistic arrangements. In situation which demands control of movement
of humans or animals appropriate personals for maintaining law and order may be required in the
team.
Composition of NHRRT:
1. National Outbreak Investigation team (NOIT)
2. National Emergency Medical Team (NEMT)
3. Communication Team
4. Others (Logistic & Law and order team)
Members:
The NHRRT shall comprise of the following multidisciplinary members:
i. Medical Epidemiologist (Team Leader)
ii. Microbiologist/Virologist
iii. laboratory technologists/technicians
iv. Clinicians
v. Entomologist and Public Health Engineering Division (PHED) (need based)
vi. Concerned Program Officers, DoPH
vii. Other relevant agency (Livestock, BAFRA,RBP): need based
3
Functions of NHRRT:
To review, verify, and advise the disease investigation and control measures implemented by
DHRRT.
If requested/needed, support DHRRT in conducting detailed field investigation of the outbreak
including confirmation of the outbreak.
Provide technical backstopping in disease investigation and containment activities to the
DHRRT.
Recommend/Provide additional resources for rapid response including supplies and medicines.
Make a detailed investigation report with recommendations for follow up by the concerned
authorities.
Provide risk communication.
Specific functions of each team of NHRRT:

National Outbreak Investigation team (NOIT): The team will be headed by an Epidemiologist.
The NOIT will conduct detailed investigation (epidemiological, environmental and laboratory
testing) of the outbreaks using the Outbreak Line Listing Form (annexure 2) and develop the
questionnaire to collect more detailed information based on the outbreak type.
National Emergency Medical Team (NEMT): Medical officer will take charge of the disease
investigation and management of cases. The team will be supported by lab technician to
collect samples and diagnosis of cases.
Communication Team: Since the event will be in a district, a local officer (DHO/ADHO) will
be in the team and will be focal person to provide any information to the media at the local
level, communicate with the District Authorities or National Authorities in case of any additional
logistic support and will also be the overall incharge of the day to day needs of the NHRRT.
Conduct awareness campaigns simultaneously to prevent further spread.
Others (Law and order, BAFRA, DoLS, vector control, Water& Sanitation team): Depending
on the type of outbreak the team will also have personnel from other units or sectors.
2.2. Dzongkhag Health Rapid Response Team (DHRRT)

The DHRRT team should be composed of persons with capacity to carry out an outbreak
investigation, conduct rapid clinical assessment, and recommend /provide some immediate
relief measures. The team leader (DHO/ADHO) will be the communication manager and through
him all communications will be made by the team. The team leader will manage the day to day
logistic arrangements for the team. In situation which demands control of movement of humans or
animals appropriate personals for maintaining law and order may be required in the team.
Composition of DHRRT:
1. District Outbreak Investigation team (DOIT)
2. District Emergency Medical Team (DEMT)
3. Communication Team
4. Others (Logistic, Law, and order team)
4
Member
The DHRRT will comprise of the following multidisciplinary members:
i. Dzongkhag Health Officer (Team Leader)
ii. Epidemiologist / FETP
iii. Medical officer
iv. Laboratory personnel
v. BHU In charge of the affected areas
vi. Extended members (need based)
a. Clinicians/specialists from Regional Referral Hospitals
b. Nursing in charge
c. Pharmacy technician
d. ADM officer
e. Other relevant agencies (BAFRA / DOL / Dzongkhag disaster management officer
Functions of DHRRT:
i. Assessment of preliminary outbreak situation in terms of number of cases, places affected for
making informed decision
ii. Carry out outbreak Investigation:
The DOIT shall conduct detailed investigation (epidemiological, environmental, and
laboratory testing) of the outbreaks using the Outbreak Line Listing Form (annexure 2) and
develop the questionnaire to collect more detailed information based on the outbreak type.
The DHRRT shall conduct enhanced surveillance to find more cases through contact
tracing.
The DHRRT shall closely monitor the situation and provide daily updates to the concerned
authorities.
The DHRRT shall seek the support of NHRRT as and when required.
The DHRRT shall update and seek support of local authorities in disease investigation and
containment measures.
iii. Control activities:
The DHRRT shall implement prevention and control measures.
iv. Report and recommendations:
The DHRRT shall produce detailed report of the outbreak and disseminate the reports to the
relevant authorities.
The DHRRT shall carry out risk communication (Refer Chapter 4: communication)
5
The DHO shall take a lead role in organization, coordination, and decision making for monitoring
the progress of outbreak investigation and implementation of control measures and for day-to-day
decision making. For this, relevant officials of Dzongkhag including Dasho Dzongda and team
leaders of DHRRT shall be involved.
Specific functions of each team of DHRRT:

District Outbreak Investigation team (DOIT): The team will be headed by an Epidemiologist.
The DOIT shall conduct detailed investigation (epidemiological, environmental, and laboratory
testing) of the outbreaks using the Outbreak Line Listing Form (Refer annexure 2) and develop
the questionnaire to collect more detailed information based on the outbreak type.
District Emergency Medical Team (DEMT): Medical officer will take charge of the disease
investigation and management of cases. He will be supported by lab technician to collect
samples and diagnosis of cases and by the nursing staff for treatment of cases.
Communication Team: At district level the DHO/ADHO who will be deployed in the team will be
focal person to provide any information to the media, communicate with the District or National
Authorities in case of any additional logistic support. He will also be the overall incharge of the
day to day needs of the DHRRT. Conduct awareness campaigns simultaneously to prevent
further spread.
Others (Law and order, BAFRA, DoLS, vector control, Water & Sanitation team): depending
on the type of outbreak the team will also have personnel from other units or sectors.
6
Chapter III
OUTBREAK INVESTIGATION
What is an outbreak?
An outbreak or an epidemic is defined as sudden eruption / occurrence of illness in a community
or a region which is clearly in excess of normal expectancy. While an outbreak is usually limited
to a small focal area, an epidemic covers large geographic areas and has more than one focal
point.
The number of cases which indicates presence of an outbreak differs according to the infectious
agents, size, and types of population affected, previous experience, lack of exposure and time
and place of an outbreak. Hence, status of an outbreak is relative to the usual frequency of the
disease in same area at a particular period of time and amongst the same population.
Definition of Excess of normal expectancy

The number of cases needed to define an epidemic varies according to the agent, the size, type,
and susceptibility of population exposed, and the time and place of occurrence. The identification
of an epidemic also depends on the usual frequency of the disease in the area among the specified
population during the same season of the year.
Diseases of pandemic nature (SARS, Ebola etc) or diseases that are in the elimination stage (e.g.
polio) occurrence of single case shall be considered as an outbreak.
In case of endemic and other notifiable diseases, the outbreak shall be defined when the number
of cases is excess of median or average number + 2 standard deviation of previous 5 yr or
average number of previous few weeks or months; 2 cases with epidemiologic linkage in short
time; single case of a emerging or re-emerging disease.
Reasons for investigating an outbreak

To identify disease and agents involved
To identify source and mode of transmission of disease
To control and contain further spread Finding will help in generation information to support policy
decisions
To address public, political, or legal concerns.
To meet international obligations
Overview of Outbreak Investigation Steps

The main goal of outbreak investigation is to minimize the public health impact of disease
outbreaks. When investigating an outbreak, speed is essential but also the right answer. Hence,
the approach to investigation should be very systematic.
7
The steps mentioned below are one that is almost universally followed by epidemiologist:
Step 1: Preparation for field work
Step 2: Confirm outbreak and diagnosis
Step 3: Define case and start case finding
Step 4: Describe the outbreak in terms of time, place, and person
Step 5: Develop hypotheses
Step 6: Test hypotheses
Step 7: Refine hypotheses and carryout additional studies
Step 8: Implement control and prevention measures
Step 9: Communicate findings
Step10: Follow up the implementation of control measures.
Step 1: Preparation for field work

Prior to conducting an outbreak investigation, it is important that the designated investigation
team (Dzongkhag RRT and National RRT) is prepared for the field visit.
Preparations should be undertaken in three areas:
a) Technical: The team members should do in-depth research on the disease through literature
review and discuss the situation among themselves, and consult other experts such as laboratory
staff, epidemiologist, and other specialists.
b) Logistics and administrative arrangements: Make necessary administrative and personal
arrangements including travel plans and other arrangements, such as ensuring that investigators
have required vaccinations, obtain required permission from authorities. RRT members should
ensure arrangement of logistics like tents, sleeping bags, cooking items, and administrative
materials as per the RRT Kit (annexure 3).
c) Coordination: Before starting the investigation, each RRT member should determine the role
as per their expertise and agree on their roles. Identify local contact at the site of an outbreak and
intimate them of your visit and purpose. Ensure proper coordination amongst team members and
field workers before, during and after the investigation.
Step 2: Confirm outbreak and diagnosis

Determine whether the outbreak is really an outbreak. In order to establish the existence of an
outbreak, one must compare current information with previous incidence in the community during
same time of the year and determine whether the observed number of the cases exceeds the
expected number. Compare the available information about the cases.
Predetermined definition of an outbreak:

If there is an abnormal increase in the number of cases or
If there is a clustering of cases or
If the cases are epidemiologically linked or
If some trigger events have occurred or if many deaths have occurred
8
Under following circumstances the presumed outbreak cannot be considered outbreak even if
the current number of reported cases exceeds the expected number because the excess will not
necessarily indicate an outbreak. The increase in reporting of case may be due to:
i. Sudden increase in population size such as resorts area, educational towns, migratory
farming practices etc.
ii. Change in local reporting procedure.
iii. Change in case definition.
iv. Increased interest because of local and national awareness.
v. Improved diagnostic procedures.
How to determine an outbreak

Normally an investigator has to compare the current number of cases with the number from the
previous weeks or months, or from a comparable period during the previous years. The source
of these data varies and most of the outbreaks can be detected through one of the three ways:
i. Indicator based surveillance
It helps in detection of an increased number of cases or an unusual pattern among cases collected
through formal surveillance systems, such as the national notifiable diseases surveillance system,
sentinel surveillance, laboratory surveillance and vector surveillance.
ii. Event based surveillance
It helps to capture information about events that are potential risk to public health. The information
can be rumors and other ad-hoc reports transmitted through formal and informal channels. The
events include clustered cases of disease or syndromes, unusual disease patterns or unexpected
deaths, events related to disease and deaths in animals, contaminated food products and water,
and environmental hazards including chemical and radio-nuclear events.
iii. Self-reported cases of illness
Cases of illness that are directly reported by a member of the public makes an important
contribution to outbreak detection because there may be substance to the complainants claim
that something (or somebody) caused the illness, and complainants tend to report promptly, so
the trail may be fresh for contact tracing. The complainant may be aware of other cases of illness
and therefore be signaling the outbreak itself.
Once the existence of an outbreak is established, verify the diagnosis by reviewing information
on clinical manifestation and laboratory test results for the disease. Following methods can be
adopted:
i. Make sure that the disease is diagnosed properly using appropriate methods and confirm
that it is really the disease that has been reported.
ii. Rule out any recent change in laboratory methods and clinical practice as the basis for the
increase in diagnosed cases
9
Every confirmed outbreak should be investigated to determine its source and to prevent further
illness. However, a rational prioritization approach is needed to determine the appropriate level
of investigation. The balance between outbreak investigation and response activities depends on
how much is known about the disease agent, source of illness and transmission mechanisms.
As soon as an outbreak is identified, preliminary data should be recorded on the outbreak reporting
system, irrespective of whether further investigation is to proceed. The decision to investigate any
outbreak should be made only after collection and reviewing of the preliminary information on the
outbreak and discussion of the situation by RRT members.
Step 3: Define case and start case finding

Compile all the routinely collected information on the cases that have been initially reported,
including incomplete information on suspected cases. Briefly review this information so that the
basis of the outbreak is clear. Identify the common features about the cases that suggest that they
are involved in the outbreak. This information will be used to produce a case definition.
Establish a case definition or a standard set of criteria for deciding if a person should be classified
as having the disease under investigation. A case definition usually consists of clinical criteria,
restriction of time, place and person.
i. Clinical information about the disease
E.g. Criteria may include presence of fever of at least 101F, three or more bowel
movement in a day, severe muscle aching, etc.
ii. Time during which the outbreak occurred
E.g. May state the time of onset of symptoms like between 10th- 20 July, 2008, past 2
months, etc.
iii. Information about the locality/place where the illness occurred
E.g. living in village X, school, working at some production plants, etc.
iv. Characteristic about person who are infected
E.g. May include an event attended after which the disease occurred; attending wedding
banquet, eating at certain hotels/ restaurants, eating some food cooked or uncooked,
swimming in the lake, etc.
v. Laboratory Result
The ideal case definition should be broad enough to include as many individuals as possible who
are likely to be part of the outbreak (sensitivity), while excluding as many as possible who are not
likely to be part of the outbreak (specificity).
Case definitions are usually classified as suspected case, probable case and confirmed case.
Suspect case: A case classified as possible usually has fewer typical clinical features of the
disease occurring in same place and time.
Probable case: A case classified as probable usually has typical clinical features of the disease
without laboratory confirmation but epidemiologically linked.
Confirmed case: To be classified as confirmed, a case usually must have laboratory confirmation.
10
Table No. 1: Example for the classification of cholera case definition
Case definition* Features
Suspected case Patient with severe diarrhea in town x between 1 June and 20 July
2013.
Probable case Patient older than 5 years with severe dehydration or dying of acute
watery diarrhea in town x between 1 June and 20 July 2013.
Confirmed case Isolation of Vibrio cholerae from stool of patient in town x between 1
June and 20 July 2013.
*Cholera outbreak
In an early part of an investigation, a loose case definition (including suspected, probable and
confirmed cases) is used to get as many cases as possible. At the later part of an investigation,
when your hypotheses come to a sharper focus, refine the case definition by dropping suspected
cases. This is useful particularly in carrying out analytic studies where gathering of further
information is required.
Identifying & Counting Cases

Use as many cases as possible to identify the case, and one might need to be creative and
aggressive in identifying these sources. Following case finding strategies can be used as per type
of outbreak:
i. Common event outbreaks:

Identifying of cases for common event outbreaks can be tightly focused on the event itself. Try
to locate a list of individuals who attended the event associated with the outbreak. If a list is
unavailable, contact the responsible person for organizing the event, and try to obtain a verbal
list of names with contact details. If neither approach is fruitful, interview cases identified
for names of other individuals attending the event. Retain names and contact details of all
individuals linked to common event outbreaks, whether cases or not, for the duration of the
investigation.
ii. Common site, dispersed and community-wide outbreaks:
Case finding strategies that are more appropriate for outbreaks in other community contexts
include:
Interviewing family contacts of cases
Reviewing notifiable disease reports
Requesting hospitals and clinicians to report patients (retrospectively or prospectively) who meet
the case definition
Requesting laboratories to report patients (retrospectively or prospectively) from whom the etiological
agent has been isolated
Reviewing data from other source
11
iii. Institutional outbreak:
Identify cases in institutional outbreaks by interviewing staff members responsible for the
institution (eg. Hospital wards, school, religious institutions).
Collect information about cases (Line listing):

Collect detailed information on all cases involved in an outbreak using a structured interview
based on a standardized questionnaire Collect the following types of information about every
person affected without consideration for particular disease under investigation:
Identifying information: name, address, telephone number etc. to allow you to and other
investigator to contact patients for additional questions and to notify them of laboratory results
and the outcome of the investigations.
Demographic information: age, sex and occupation to provide details to characterize the
population at risk.
Clinical information: information that will allow you to verify that the case definition is met.
Date of onset which will allow creating a graph of the outbreak. Supplementary clinical
information may include hospitalization or death of the patient. This will assist us in describing
the spectrum of illness.
Risk factor information: enable an investigator to tailor the investigation to the specific
disease in question. For instance it will enable the investigator to look at exposure of the
person to food and water sources if he is suffering from hepatitis A.
Based on the questionnaire, develop a line listing of the cases shown as example in the table
below:
Table No. 2: Line listing of demographic, clinical and exposure characteristics of food borne
disease outbreak of 4 cases at place X.
12
Step 4: Describe the outbreak

Any outbreak should be characterized in terms of time, place and person. For this descriptive
analysis is used.. The information collected through line listing and questionnaire will be used for
descriptive data analysis.
Descriptive epidemiology is done to:
1. Familiarize with the data; study what information is reliable and informative; and what may
not be reliable.
2. Provide comprehensive description of an outbreak by showing its trend over a period of time,
its geographic extent and population affected by the disease. This description will help to
commence assessing the outbreak in light of what is known about the disease and develop
casual hypothesis and in turn test this hypothesis using technique of analytic epidemiology.
It should be noted that descriptive epidemiology should be done early during the course of an
outbreak and update it as you collect additional data.
Characterizing by person:
Characterizing an outbreak by person refer to groups of people having similar personal
characteristics like age, race, sex, or medical status or by exposure like medication, use of tobacco,
drugs, etc. These factors are important because if a disease agent has not been identified by
laboratory testing, predominant signs and symptoms among cases may be useful in identifying
the agent and directing further laboratory testing.
First assess age and sex as they are often the characteristics most strongly related to exposure
and the risk of the disease. Other characteristics will be more specific to the disease under
investigation and setting of the outbreak.
Characterizing by place:
Assessment of an outbreak by place will provide information on geographic extent of a problem
and may also show cluster or pattern that will provide clue for identifying an origin of the outbreak.
To look at the geographic pattern, a simple technique to do so is to plot spot map.
A spot map will show clusters or pattern that reflects water supplies, wind current, or proximity
to a restaurant or grocery shop. On spot map of a hospital or BHU, clustering usually indicates
either a focal source or human-human spread, while scattering of cases throughout the facilities
is more consistent with a common source such as dining hall. Person and place associations can
be assessed most easily by examining variables within a line listing of cases.
The disadvantage of using spot map lies in the fact that if comparison of the population sizes
between the areas varies, results can be misleading as it shows you the number of cases. Show
the proportion of people affected in each area (which would also represent the disease or, in the
setting of an outbreak, the attack rate) in such cases.
13
Characterizing by time:
Show the time course of epidemic by drawing a graph of the distribution of cases by onset of
symptoms. This graph is called epidemic curve or Epi curve. It gives a simple visual display of
outbreak magnitude and time trend.
Benefits of using Epi curve:-

An epidemic curve will be able to tell an investigator where they are in the course of outbreak
investigation and to predict its future course. If the disease is identified and know its usual
incubation period, probable time period of exposure can be estimated and develop questionnaire
focusing on the time period. You may be able to infer about epidemic pattern.
The example on how to draw and interpret an epidemic curve is given in the annexure 4.
Review the information and decide whether to progress for further investigation.
Information gained from the descriptive phase, in combination with the environmental investigation
and the results of laboratory testing, should be sufficient to characterize the outbreak and may
also indicate the likely outbreak source and mode of transmission.
The next stage of the investigation is the application of intensive analytic epidemiological methods,
environmental investigation or laboratory investigation.
The primary reasons for progressing for further investigation are:
i. If the descriptive stage of the investigation has not adequately informed the development and
implementation of measures to control the outbreak or prevent further outbreaks occurring
due to the same source.
ii. On-going nature of the outbreak.
iii. High public health impact of the outbreak
iv. Increased public concern about the current outbreak
v. New or unusual disease agent or transmission mechanism
vi. An unknown disease agent, likelihood of a common source
vii. Investigation required on special command.
Regardless of the decision to undertake further investigation, it is important to implement
precautionary control measures to stop further spread of the disease.
Step 5: Develop Hypotheses

Hypothesis is necessary to explain why and how the outbreaks occurred in that particular place
when we first learn about the problem. A hypothesis should address source of agent, mode of
transmission, exposure that caused the disease. It should also be proposed in such a way that it
can be put into tests.
Hypothesis development can be done by considering either of the followings:
i. Consider what is known about the disease itself: what is the agents usual reservoir? What
are the modes of transmission? What are the known risk factors?
14
ii. Hypothesis can also be generated by talking to the people infected. Conversation on the
possible exposure should not be confined to known sources and vehicles. It should be open-
ended and wide-ranging. It would be also useful to visit homes of infected people to look for
clues to develop the hypothesis.
iii. Even descriptive epidemiology often provides some hypotheses. If the epidemic curve points
to a narrow period of exposure, ask what event occurred at that time. If the people living in the
area have the highest attack rate, or if some group in the particular area of same age, sex, or
other personal characteristics is at greatest risk, ask why? Such questions will gradually lead
to the hypotheses that can be tested.
Step 6: Test Hypotheses

There are two ways by which you can evaluate your hypotheses depending on the nature of data:
i. Compare your hypotheses with the established facts:

Do this if the evidence is so strong that the hypotheses need not be tested and no further
analysis is necessary.
ii. Analytic epidemiology: which will allow to test the hypotheses:
This method is used when the exact cause is not clear and thus there is a need to test the
hypotheses using comparison group to quantify relationships between different exposures
and the disease. For hypothesis testing it may be necessary to carry out detail investigation
using appropriate study design like cohort, case control etc for detail information on the study
design refer annexure 5.
a. Cohort studies
Group whose members share a significant experience at a certain period of time or have one
or more similar characteristics. Researchers observe what happens to one group thats been
exposed to a particular variable for example, the effect of company downsizing on the health
of office workers. This group is then compared to a similar group that hasnt been exposed to the
variable. For detail refer annexure 5.
b. Case control
In most outbreaks the population is not well defined, and so cohort studies are not feasible. In
these instances, you would use the case-control study design. In a case-control study, ask both
case-patients and controls about their exposures then calculate a simple mathematical measure
of association called anodds ratio to quantify the relationship between exposure and disease.
This method does not prove that a particular exposure caused a disease, but it is very helpful and
effective in evaluating possible vehicles of disease. For detail refer annexure 5.
Step 7: Refine Hypotheses and carry out additional studies:

When analytic epidemiology do not answer the developed hypothesis or do not confirm an
outbreak, reconsider the hypotheses and look for new vehicle or the mode of transmission. This
is an opportunity to meet with the case patients to look for a common links and to visit their homes
to look at the product on their shelves.
15
Refine the hypotheses even if it is found that there is relationship between exposure and the
disease and sometimes more specific exposure histories or more specific control group might be
necessary. There may be a need to consider using two or three sequential case control studies
for identifying the vehicle.
When an outbreak occurs, routine or unusual, consider what questions remain unanswered about
the disease and what kind of study might be used in particular to answer some of these questions.
Such circumstances enable us to learn more about the disease and its characteristics: such as
mode of transmission, causative agents, vehicles and host factors.
7.1. Laboratory Investigation:

Laboratory evidence will help the outbreak investigation team to confirm the findings. The
laboratory assists outbreak investigators advising on the range of plausible organisms and toxins
involved in an outbreak to help focus the epidemiological and environmental components of the
investigation. Therefore it is essential for the investigators to collect appropriate and adequate
samples for analysis. It is also imperative to handle carefully those collected samples to transport,
store at appropriate temperature so that good result is obtained.
As soon as the laboratory investigation is deemed necessary during outbreak the team should
contact the laboratory immediately. A focal person of the laboratory should be identified and
contacted all the time during the investigation period so that continuity throughout the outbreak
investigation and response is maintained. The investigators should request the laboratory to save
specimen for future studies and additional testing.
Specimen collection, storage and transport

Make plans for specimen collection, storage, transport, receipt and testing as clearly and as early
as possible. The laboratory should always be consulted about specific requirements, including
transport and temperature. Equipment such as special containers and processing reagents may
need to be organized, especially if chemical toxin testing is planned.
Generally the number and amount of samples to be sent to the laboratory depend on range
of pathogens to be detected and test parameters requested. Therefore, outbreak investigators
need to discuss with laboratory personnel prior to collection of clinical, food and environmental
samples. For details refer annexure 6.
Interpretation of laboratory result

Although laboratory test results are generally used to support a diagnosis or hypothesis, test
results may not be 100% accurate as the methods have variation in sensitivity and specificity.
Therefore, a positive result from a person or item without epidemiological association does not
prove the person or item was a source or vehicle of infection. On the other hand, a positive result
from an epidemiologically implicated person or item strongly suggests that person or item was
most likely a source or vehicle of infection.
7.2. Environmental Investigation

Environmental studies are very important in some settings as they help in explaining why an
outbreak occurred. Thus the epidemiologic, environmental, and laboratory complement each
16
other. While you may not be an expert in these areas but you can help. Use a camera to photograph
the environmental conditions. Coordinate with the laboratory, and bring back physical evidence to
be analyzed. The table below explains uses and components and environmental samples to be
collected during environmental investigation in different outbreak settings.
Table No.3: Summary of environmental investigation*
Outbreak type Role of environmental investigation

Common event Environmental investigation is very important in the overall investigation
of common event outbreaks. Components of environmental investigation
of common event outbreaks include hazard identification and collection of
environmental specimens. For enteric disease outbreaks, environmental
investigation should include identification of infected food handlers,
collection of leftover food for testing and hazard assessment of food
preparation processes
Common site Environmental investigation of common site outbreaks is necessarily
preceded by identification of the site itself. Once the site has been
identified, environmental investigation of common site outbreaks parallels
that of common event outbreaks is necessary
Dispersed Environmental investigation of dispersed outbreaks is necessarily preceded
by identification of the site. It may involve product tracing backs to identify
the sites and the processes involved in contamination
Community-wide Environmental investigation of community-wide outbreaks is rare. In
unusual circumstances, environmental investigation may involve tracing
back of vaccine supplies or investigation for breaches of the vaccine cold-
chain
Institutional Environmental investigation of institutional outbreaks is similar to common
event outbreaks in that the site of transmission is known at the outset.
Investigation should involve hazard identification and collection of
environmental specimens
* Source: Adapted from guidelines for the investigation and control of disease outbreaks, 2012
Step 8: Implement control and prevention measures

The main goal of an outbreak investigation is to control an outbreak and apply preventive
measures. Indeed, control measures should be implemented as soon as possible though it is
being described under this step so as to make it systematic. Usually control measures must be
implemented early if the source of an outbreak in known. The control measures should be aimed
at the most appropriate point to break the chain of infection and at the specific agent, source, or
reservoir. For more examples refer Table 3 at annexure 7.
Step 9: Communicate Findings

It is important to communicate the findings of the investigation to relevant stakeholders, community
and health personnel. Communicate the findings in two ways;
17
1. By giving oral briefing for the local health workers like CMO and HA and other agencies
for whom your information is useful.
It should be attended by the local health authorities and people responsible for implementing
control and prevention measures. It is an opportunity to tell them what was being done, what
was found, and recommend what should be done. This is also an opportunity to present the
findings in scientifically objective manner.
2. In a form of written report.
A written report should summarize the investigation and must be prepared as soon as the
investigation of an outbreak is complete. This report should contain various information (refer
annexure an example of preparing of report on investigation of an outbreak).
A report should be written in a scientific format. By giving recommendations formally, it
provides a blueprint for actions to tackle an outbreak. And it is a key part of the medical report.
It can be useful education tool for the health workers and authorities as well. Hence the
report prepared will find its way into the public health literature and serve the wider purpose
of contributing to scientific knowledge bases of epidemiology and public health. For details
refer annexure 8.
Step 10: Follow-up of implementation of control measures

It is important to follow-up and ensure implementation of recommendations and control measures
and assess its effectiveness. Monitor for emergence of any new cases for at least two incubation
periods after implementation of control measures. An absence of new cases for at least two
incubation periods of the infectious disease under investigation could suggest that the outbreak
is subsiding. Individuals need to be monitored for symptoms of new cases, treat individuals for
complications and public heath interventions, and implementation of outbreak recommendations
also need to be monitored to assure public health security.
Table No. 4: Summary of Outbreak Investigation Steps and Management

Outbreak Investigation Individual or group
Outbreak Investigation component
step Responsible
Step 1: Preparation of Identify RRT members DHO at district,
field work Surveillance unit of PHL at
Coordination meetings with RRT members
national level
Stockpiles: sampling kits, appropriate
antibiotics, intravenous fluids
Assembling materials necessary for outbreak
investigation and response
Contingency plans for isolation wards in
hospitals
Laboratory support
18
Step 2: Confirm outbreak Outbreak Detection: Routine surveillance DHO at district,

& diagnosis. Surveillance unit of PHL at
Analysis of notifiable disease surveillance
national level
system at district / National level
Regular examination of surveillance data
to detect increase in disease incidence and
common risk factors
Collection of notification from clinicians and
laboratories
Collection of data on self reported cases and
other informal reporting sources
Collection of descriptive information on
individual case of disease with outbreak
potential.
Step 3: Define case & Compile routinely collected information about Rapid response team
start case finding. cases involved with outbreaks.
Establish outbreak case definition.
Identify & count cases as per the case
definition.
Step 4: Descriptive data Characterization of outbreak by person, Rapid response team

collection and analysis place and time
Step 5: Develop Development of hypothesis Rapid response team

hypothesis
Identification of need for further investigation
Step 6: Analytic studies to Compare hypotheses with the established Rapid response team
test hypotheses facts if the evidence is so strong that the
hypotheses need not be tested and no further
analysis is necessary.
Analytic epidemiology: used when the
exact cause is not clear. Test the hypotheses
using analytical epidemiology approach:
Cohort & case control studies.
Step 7: Carry out Capacity for Laboratory and environmental Rapid response team
additional studies investigation
Investigation
Step 8: Implement control Implementation of control measures. Rapid response team,

& prevention measures Local authority
19
Step 9: Communicate Incidence reports within one week of DHO at district,

findings recognition, updated weekly, final record Surveillance unit of PHL at
within one week of completion. national Level
Communication with media about district
outbreaks.
Documentation of outbreak
Timely and accurate reporting of the entire
outbreak via outbreak surveillance system.
Step 10: Follow up the Monitor for emergence of any new cases Local health authority,
implementation of control for at least two incubation periods after DHO at district,
measures. implementation of control measures. Surveillance unit of PHL at
national.
Documentation and
reporting
20
Chapter IV
COMMUNICATION DURING OUTBREAK INVESTIGATION

A coordinated approach to communication is an essential part of outbreak investigation
activities. Disease outbreaks occur at unexpected times and can grow rapidly in scale and attract
considerable attention from the media, public, and government agencies. A planned approach
to communication will help the outbreak team to remain focused on the investigation, know that
information circulating about the outbreak is accurate and that relationships with other agencies
are being maintained.
Effective interagency communication is particularly important to get the support from relevant
agencies during the investigation and response to outbreak. This section of the manual describes
the details procedures of disseminating accurate information to every stake holders during
outbreak containment exercise.
Communication expertise
It is important that staff involved in outbreak investigation have risk communication training.
In major outbreak situations and emergencies local leaders can be called upon to inform the
public/community on the risk communication as well as to build public cooperation and support
in responding to the outbreak and recovery measures. Risk communication is a tool for closing
the gap between laypeople and experts, and helping stakeholders make more informed decision.
Using available information and the necessary expertise, action must be taken usually with some
urgency while making the community understand and accept the uncertainty.
Communication plans
The communication plan should address four key areas:
1. Communication within the outbreak team/RRT
2. Communication with the Ministry of Health and relevant government agencies.
3. Communication with the public and media
4. Communication with other agencies involved in the outbreak, such as local authorities,
business groups, district hospitals and BHU, animal health sector, school authorities etc
1. Communication within the RRT:
The process may be straight forward if the team is small and shares the same workplace, but will
need to be considered more explicitly if the outbreak investigation involves multiple districts or
involves multiple levels/sectors.
21
Use the following principles:

Outbreak team leader (DHO) should organize and chair team meetings with the Rapid
Response Team.
Each meeting should include a summary of the outbreak as it is initially presented, an update
on overall progress, and then invite contributions from each member of the investigation.
Make sure that problems and barriers to the investigation are presented and discussed in the
report.
Communication in the field should be through phone/fax/email/sms. Make sure that a list of
contact numbers for outbreak RRT members is compiled, accurate, and distributed to each
RRT member
2. Communication with the public and media
Communicating with the public and media gives the opportunity for providing essential advice on
initial control measures to the public, while at the same time providing an opportunity to deliver
important health prevention/promotion messages relevant to the outbreak (e.g. behavioural
changes). Also, it provides early, accurate and on-going information about the situation, even if
uncertainty exists, and about the progress of the investigation.
At the district level, District Health Officer (spoke person) is responsible for responding to media
enquiries and for managing public and media communication. There would be also a national
level spoke persons who would be the designated media (spokesperson) focal person in MoH.
While communicating with public and media, it would be important to follow the following WHO
principles for risk communication:
Tell the people who are most affected what you have found, and tell them first.
Make sure people understand what you are telling them and what you think the implications
are.
Develop a mechanism to bolster the credibility of your study and your findings.
Apply epidemiological expertise where it is called for and do not misapply it where it is unlikely
to help.
Show respect for public concerns, even when they are not scientific.
Acknowledge uncertainty promptly and thoroughly.
It is important to provide accurate information. Tell the truth and do not exaggerate, if you make
a mistake, correct it, and if you do not know, say so. You may be able to offer to find and provide
more information later that day. It is also important to communicate information effectively.
Therefore, get your message in early, repeat it if necessary, and say it in an interesting way. Use
simple language and avoid technical terms.
The risk communication activities can be also carried out by the RRT members in affected
communities through door-to-door visit while carrying out the investigation. They can advise on
DOs and Donts on the control measures.
22
3. Communication with the Ministry of Health and PHL
It is important to inform the Ministry of Health and Surveillance Unit under PHL during the early
stages of any significant outbreak investigation. It can be a phone call to PHL, concerned program
with brief verbal report followed by a written incident report, daily update and progress report on
the investigation and containment activities. This would keep the national level updated for any
policy directives required.
Figure 3: Channel of communication during outbreak (within health sector & relevant agencies)
4. Communication with other relevant agencies (National/international)\

Communicating with relevant agencies during outbreak investigation is important at all levels.
This would enhance cooperation and support required in conducting the outbreak investigation.
At the national level, Department of Public Health is responsible in communicating with the
designated international agencies like WHO and other ministries/sectors on the outbreak through
NICC. At district level, the District Health Office will communicate with the relevant agencies, and
the health facilities within the district about the outbreak.
23
Annexure 1
Specific roles and responsibilities:

i. Dzongda (Chairman- District Health RRT):
Oversee the functions of district RRT.
Provide administrative directives and support to the district RRT.
Ensure emergency contingency fund for disease outbreak.
Support and facilitate the recommendation of the outbreak report for future outbreak
prevention and preparedness plan.
Participate in communication of unusual health events in the district.
Facilitate inter-sectoral coordination for necessary support during management of outbreak.
ii. District Health Officer:

Carry out surveillance activities and risk analysis of diseases.
Review routine data, analyze and give feedback to the medical officer and the BHU staff.
Predict and plan for potential future outbreaks.
Determine resources needed for rapid response and disease investigation.
Ensure availability of personnel for rapid response.
Maintain an inventory of resources for rapid response and outbreak investigation as per
the Rapid Response Kit list.
Conduct simulation exercises and training of RRT annually.
Lead district RRT during disease outbreak as Team Leader.
Establish clear lines of responsibility for planned actions during disease outbreak.
Ensure equipments needed for establishment of Emergency Operation Center (Refer EOC
guideline).
Communication with the general public and the media during disease outbreak.
Collaborate and coordinate with other relevant agencies in managing the outbreak.
Prepare report in consultation with the medical officer involved in managing the disease
outbreak.
Maintain archive of outbreak reports.
24
iii. Medical Officer:

Provide technical support for training of RRT.
Create awareness to hospital staff on unusual events reported in the OPD.
Alert DHO & PHL on unusual events reported in the OPD or in-patient.
Develop Hospital Contingency plan for management of any unusual events.
Provide technical guidance to RRT during outbreak investigation.
Participate in case management during the outbreak.
Assess the need for technical support from higher level.
Help in preparing outbreak investigation report.
Assist DHO in communicating with media and public during outbreak management.
Impact assessment of disease outbreak .
iv. BHU staff during outbreak

Review routine data at the BHU.
Be alert to any unusual events in the BHU and community.
Report/inform to DHO of an unusual event (during and after the event assessment).
Assess the event and collect information on nature of outbreak.
Alert local leaders on the unusual events for support and information.
Arrange local logistics for RRT.
Daily follow up on outbreak situation (old cases, any new cases) until at-least 2 incubation
periods.
25
Annexure 2
Outbreak line listing form:
26
Annexure 3
Rapid Response Kit:

Personal Protective Equipment (PPE)
Face Mask
Gown
Sanitizer/hand rub
Goggles
Boots
Hair-cover
Gloves
Torch/emergency lights
Drugs
IV-fluids and sets
Biohazard bags
Safety box/First aid box
Sampling kits
Cold box
Sample vials
OHP-markers
Swabs
Forms (lab and outbreak investigation forms)
Rapid Diagnostic kits
Syringe and needles
Spirit swabs
27
Anexure 4
Example on how to draw epidemic curve:

Draw an epidemic curve
An epidemic curve depicts the time course of the onset of symptoms among cases in an outbreak.
The epidemic curve is a two-dimensional bar graph or histogram with an x- and a y-axis that
helps to illustrate the dynamics of the outbreak, including the number of people affected the time
course of the outbreak and whether the outbreak is continuing. It may also indicate the mode of
transmission and help to relate the timing of key events (such as possible exposures and control
measures) to the onset of symptoms.
The epidemic curve has the following format:

The x-axis depicts the time or date of onset of symptoms. Choose an x-axis scale based on the period
covered by the outbreak and the incubation period of the disease.
The y-axis depicts the number of cases. The scale of the y-axis will depend on the number of cases
involved in the outbreak
Interpreting the epidemic curve

The shape of the curve may indicate the mode of transmission.
The epidemic curve of a common event outbreak has a sharp rise in cases to a peak, followed by a
fall-off that is less abrupt than the rise (Figure 4). The length of the curve will be approximately equal
to one incubation period of the infection.
The rise in cases for a dispersed or common site outbreak may also be sharp, but will not fall off unless
exposure to the source is discontinued or all susceptible individuals become infected.
The epidemic curve of a community-wide outbreak, with person-to-person spread, is likely to be

characterized by a relatively slow, progressive rise. The curve will continue over a period equivalent to
the duration of several incubation periods of the disease (Figure 5).
The epidemic curve of an institutional outbreak may resemble any of the above, depending on the
mechanism of disease transmission. Epidemic curves may not exactly fit any of these models. The
outbreak may have mixed characteristics, and random variation may also affect the shape of the curve.
28
Calculate an incubation period:

The incubation period is the interval between exposure to the disease agent and appearance
of initial symptoms of the illness. While each disease has a characteristic incubation period, the
incubation period for the disease will vary among individuals, due to physiological variations,
differences in the degree of exposure to the disease agent and biological factors that influence
susceptibility.
The incubation period has two main uses when investigating disease outbreaks. If the exposure
time is known, calculation of the incubation period can help to narrow the range of possible
disease agents and will therefore direct subsequent laboratory tests and control measures. If the
disease agent is known, but the time of exposure is not, the incubation period (as recorded in the
published literature) can determine the approximate time of exposure, enabling the outbreak team
to narrow the focus of the remainder of the investigation, including any analytic epidemiological,
environmental and laboratory components.
Calculate the incubation period for each individual by subtracting the time of exposure from the
time of onset of the first symptoms consistent with the case definition. Note the shortest and
longest incubation periods (i.e., the range) in the group.
Calculate the incubation period for the group by using the median or mean. The median incubation
period is calculated by sorting incubation periods from the shortest to the longest. The median
incubation period is the incubation period of the individual at the mid-point on the list (or the
average of the two middle values if the list has an even number of cases). The mean incubation
period is the average or the sum of all incubation periods divided by the number of observations.
In practice, the median incubation period is often preferred because, unlike the mean incubation
period, it is not influenced by a small number of cases with extremely short or long incubation
periods (called outliers).
The table 5 below presents case data for 10 people who developed nausea and vomiting following
a dinner party at a restaurant. The table shows times of exposure and onset of illness, and
the calculated incubation period for each person who became ill. The mean incubation period
was 9.7 hours and the median incubation period was 6.5 hours (range: 342 hours). This short
incubation period and the clinical presentation are highly suggestive of the ingestion of a bacterial
enterotoxin, such as that of Staphylococcus aureus, Clostridium perfringens or Bacillus cereus.
29
Table 5: Sample case data for calculation of incubation period.
Patient Time of exposure Onset of symptoms Incubation period
1 7:00 pm(13/4/91) 10:00 pm (13/4/91) 3.0
2 7:00 pm 11:30 pm 4.5

3 7:00 pm 12:00 am 5.0
4 7:00 pm 12:00 midnight (14/4/91) 5.0
5 7:00 pm 1:00 am 6
6 7:00 pm 2:00 am 7
7 7:00 pm 2:00 7
8 7:00 pm 3:30 am 8.5
9 7:00 pm 4:00 am 9
10 7:00 pm 1:00 pm (15/4/91) 42
Two points are notable from this example. First, the mean incubation period was somewhat
longer than the median. In fact, the mean is longer than all but one of the incubation periods. This
demonstrates how one particularly unusual value, that is 42 hours, can have a major impact on the
mean. Secondly, it is highly likely that the case with the apparent 42-hour incubation period had
an illness unrelated to the initial outbreak. This person may have had nausea and vomiting due
to some other cause, or may have been exposed later than the other dinner guests, for example,
through secondary infection or eating leftovers sometime later. Re-examine such outliers to
determine whether the patient was really likely to have been associated with the outbreak. It may
sometimes be necessary to exclude the outlier(s) when determining the incubation period.
30
Annexure 5
Analytic studies: Cohort and Case control

a. Cohort Studies
Criteria for using the retrospective cohort study design:
Retrospective cohort study design can be used for outbreaks confined to a group that is well-
defined, easy to count and within which everyone may be identified, regardless of whether they
became ill or not. Therefore, this study design is most useful for the investigation of common
event, institutional and household outbreaks. Examples include outbreaks involving children at a
particular school, or attendees at a particular social event. A complete list of those in the group is
desirable (e.g., the school roll or a guest list). This list defines the study cohort, and includes both
cases and non-cases.
Retrospective cohort study designs are generally not used for investigating dispersed, common
site and community-wide outbreaks where the potentially exposed group cannot be enumerated.
If investigation of the whole cohort is unfeasible, a cohort design can still be applied by taking a
random sample of the cohort for study. The main disadvantage with this approach is that identified
cases may not be included within the random sample. If this is an issue, it may be more appropriate
to use a case-control design.
Designing and analysis of a retrospective cohort study:
A cohort study is the best technique for analyzing an outbreak in a small, well-defined population.
For example, you would use a cohort study if an outbreak of gastroenteritis occurred among
people who attended a social function, such as a wedding, and a complete list of wedding guests
was available. In this situation, you would ask each attendee the same set of questions about
potential exposures (e.g., what foods and beverages he or she had consumed at the wedding)
and whether he or she had become ill with gastroenteritis.
After collecting this information from each guests, you would be able to calculate an attack rate for
people who ate a particular item (were exposed) and an attack rate for those who did not eat that
item (were not exposed). For the exposed group, the attack rate is found by dividing the number
of people who ate the item and became ill by the total number of people who ate that item. For
those who were not exposed, the attack rate is found by dividing the number of people who did
not eat the item but still became ill by the total number of people who did not eat that item.
To identify the source of the outbreak from this information, you would look for an item with:
A high attack rate among those exposedand
A low attack rate among those not exposed (so the difference or ratio between attack rates
for the two exposure groups is high);in addition
Most of the people who became ill should have consumed the item, so that the exposure
could explain most, if not all, of the cases.
Usually, you would also calculate the mathematical association between exposure (consuming
the food or beverage item) and illness for each food and beverage. This is called therelative
riskand is produced by dividing the attack rate for people whowere exposedto the item by the
attack rate for those whowere not exposed.
31
Basic analysis of results from a retrospective cohort study:

The calculation of attack rates and risk ratios is illustrated using the following two-by-two table
that shows the relationship of the disease to a particular exposure
Disease Present
Exposure Yes (Case) No (non-case)
Yes A B
No C D
After collecting this information from each guests, we would be able to calculate an attack rate
for people who ate a particular item (were exposed) and an attack rate for those who did not eat
that item (were not exposed). The calculation of attack rates and risk ratios is illustrated using
the following two-by-two table that shows the relationship of the disease to a particular exposure.
Number of people with disease in the sub-group

Attack Rate = x100
Number of people in the sub-group
a
Attack rate for exposed sub-group = X 100
a +b
c
Attack rate for un-exposed sub-group = X 100
c +d
Attack rate for exposed sub-group

Risk Ratio =
Attack rate in corresponding non-
exposed group
a c
Risk Ratio =
a +b c+d
Population Attributable Risk (PAR):
PAR = risk (incidence) in population risk (incidence) in

non-exposed
Population Attributable Risk % (proportion or fraction):
PAR % = PAR / risk (incidence) in population
b. Case-control studies
Case control study: Here researchers use existing
records to identify people with a certain health problem
32
(cases) and a similar group without the problem
(controls). Example: To learn whether a certain drug
causes birth defects, one might collect data about
children with defects (cases) and about those without
b. Case-control studies
Case control study: Here researchers use existing records to identify people with a certain health
problem (cases) and a similar group without the problem (controls). Example: To learn whether
a certain drug causes birth defects, one might collect data about children with defects (cases) and
about those without defects (controls). The data are compared to see whether cases are more
likely than controls to have mothers who took the drug during --pregnancy.
Criteria for using a case-control design

The case-control study design is appropriate for the analytic epidemiological component of an
outbreak investigation as follows:
Where cases have been identified, but the entire at risk or potentially exposed group cannot
be completely listed. They are therefore most useful for the investigation of dispersed,
common site and community-wide outbreaks. Examples include outbreaks involving
shoppers at a supermarket or people living in a particular area
For the investigation of a common event outbreak where the size of the cohort is unfeasibly
large or the number of cases represents a small proportion of the total at-risk population
For the investigation of risk factors for apparently sporadic disease
When designing a case-control study, most important decision is who the controls should be.
Conceptually, the controls must not have the disease in question, but should be from the same
population as the case-patients. In other words, they should be similar to the case-patients except
that they do not have the disease. Common control groups consist of neighbors and friends of
case-patients and people from the same physician practice or hospital as case-patients.
In general, the more case-patients and controls you have, the easier it will be to find an association.
However, this study design are limited if the outbreak is small. For example, in a hospital, 4 or 5
cases may constitute an outbreak. Fortunately, the number of potential controls will usually be
more than needed. In an outbreak of 50 or more cases, 1 control per case-patient will usually
suffice. In smaller outbreaks, you might use 2, 3, or 4 controls per case-patient. More than 4
controls per case-patient will rarely be worth your effort.
In a case-control study, you cannot calculate attack rates because you do not know the total
number of people in the community who were and were not exposed to the source of the disease
under study. Without attack rates, you cannot calculate relative risk; instead, the measure of
association you use in a case study is an odds ratio. When preparing to calculate an odds ratio,
it is helpful to look at your data in a 22 table.
For instance, suppose you were investigating an outbreak of hepatitis A in a small town, and you
suspected that the source was a favorite restaurant of the townspeople. After questioning case-
patients and controls about whether they had eaten at that restaurant, your data might look like
this:
Case Patients Controls Total
Yes a = 30 b = 36 66
Ate at Restaurant A?
No c = 10 d = 70 80
Total: 40 106 146
33
The odds ratio is calculated as ad / bc. The odds ratio for Restaurant A is thus 30 70 / 36 10,
or 5.8. This means that people who ate at Restaurant A were 5.8 times more likely to develop
hepatitis A than who did not eat there. Even so, you could not conclude that Restaurant A was the
source without comparing its odds ratio with the odds ratios for other possible sources. It could
be that the source is elsewhere and that it just so happened that many of the people who were
exposed also ate at Restaurant A.
Table No. 6: Advantages and Disadvantages of Case-Control and Cohort Studies
Case-Control Cohort
Advantages: Advantages:
1. Useful in the study of rare diseases. 1. Good for rare exposures
2. Permits the study of diseases with long 2. Can look at multiple outcomes of the same
incubation period exposure
3. Can be conducted over relatively short 3. Minimizes recall bias
time periods.
4. Measure the risk of developing a disease based
4. Relatively inexpensive as compared to on exposure
cohort studies.
5. Provide a clear temporal sequence of exposure
5. Can study multiple potential causes of and disease.
disease.
6. Permit calculation of incidence rates as well as
relative risk.
7. Results easily understood by non-
epidemiologists.
Disadvantages: Disadvantages:
1. Assess single outcome (disease) only 1. Expensive, takes a lot of time and resources
2. Inefficient for rare exposures. 2. Not suitable for studying rare diseases.
3. Cant measure the risk of developing a 3. May require large sample depending on how
disease. frequent the outcomes are and the size of the
cohort.
4. There may be recall bias.
4. Takes a lot more time than case control studies.
5. Choice of appropriate control group
may be difficult. 5. Retrospective cohort studies may have recall
bias
6. Cannot usually provide information on
incidence rates of disease. 6. Selection bias.
34
Testing statistical significance

The final step in testing your hypothesis is to determine how likely it is that your study results
could have occurred by chance alone. In other words, how likely is it that the exposure your study
results point to as the source of the outbreak was not related to the disease after all? A test of
statistical significance is used to evaluate this likelihood.
The first step in testing for statistical significance is to assume that the exposure is not related
to disease. This assumption is known as the null hypothesis. Next, compute a measure of
association, such as a relative risk or an odds ratio. These measures are then used in calculating
a chi-square test (the statistical test most commonly used in studying an outbreak) or other
statistical test. Once you have a value for chi-square, look up its corresponding p-value (or
probability value) in a table of chi-squares.
In interpreting p-values, set in advance a cutoff point beyond which you will consider that chance
is a factor. A common cutoff point is 0.05. When a p-value is below the predetermined cutoff point,
the finding is considered statistically significant, and you may reject the null hypothesis, that is
to conclude that the exposure is associated with disease. The smaller the p-value, the stronger
the evidence that the finding is statistically significant.
35
Annexure 6
Collection of clinical samples based on suspected disease.
Sl. Syndromes/ Responsible When to collect What to collect Storage Transportation To Confirm
Diseases Pathogens/toxins Case(s)
No.
1 Anthrax Bacillus anthracis A single case of suspect Blood, sample from At 2-8C for seven Immediately Isolation of Bacillus
(cutaneous) anthrax with any of the opened vesicle or days. In case of delay in transport anthracis from
clinical forms from below eschar. in transportation, media at room blood and/or skin
store at -20C deep temperature lesion swab and/
freezer or detection of
antibodies in
serum.
Anthrax Blood, stool Isolation of Bacillus
(gastrointestinal) sample/rectal swab anthracis from
36
blood and/or stool
and/or detection
of antibodies in
serum.
Anthrax Blood, respiratory Immediately at Isolation of
(pulmonary) secretions 2-8C Bacillus anthracis
from blood and/
or respiratory
secretions and/
or detection of
antibodies in
serum.
2 Acute Bloody 1. Shigella ssp., A cluster* of acute Stool sample/rectal Culture isolates at Immediately in Isolation of
Diarrhea (ABD) 2. Salmonella ssp., bloody diarrhea swab for culture -20 C. transport media Shigelladysenteriae,
3. Entero-hemorrhagic and blood for at 2-8 C Salmonella
E. coli, serology. species and other
4.Entamoebahistolytica, pathogens from
5. Campylobacter jejuni blood or stool.
3 Acute Watery 1. Rotavirus, A cluster* of acute Stool sample/rectal Culture isolates at Immediately in Testing for
Diarrhea (AWD) watery diarrhea swab -20 C. transport media rotavirus (ELISA)
2. Vibrio cholerae,
at 2-8 C if mainly children
3. Noroviruses, under 5 years of
age and for Vibrio
4. Staphylococcus
cholerae if mainly
aureus,
people older than 5
5. Entero-toxigenic years affected.
E.coli, A single case of suspect Stool sample/rectal Culture isolates at Immediately in Isolation of Vibrio
cholera: a person > swab -20 C. transport media cholera O1 or
6. Campylobacter jejuni,
5 years of age with at 2-8 C O139
7. Other viruses, severe dehydration or
death from acute watery
8. Other bacteria
diarrhea
4 Acute Flaccid Poliovirus A single case of AFP Stool sample/ At 2-8 C Immediately at Laboratory-
Paralysis (AFP) (within 14 days onset of rectal swab: two 2-8C confirmation of
AFP) specimens to be wild poliovirus in
collected 24 hours stool sample can
37
apart be performed at
Reference Lab in
Thailand.
5 Acute 1. Dengue virus, A single case of acute Blood sample At 2-8C for 7 days. At 2-8 C Dengue rapid
Haemorrhagic hemorrhagic fever In case of delay test in endemic
2. Leptospira,
Fever Syndrome syndrome in transportation, areas and dengue
3. Neisseria meningitidis, store at -20C deep antibody detection
freezer. (ELISA) at PHL.
4. Others
Leptospirosis rapid
test at PHL.
6 Acute Jaundice 1. Hepatitis A, B, C, D, A cluster* of acute Blood sample At 2-8C for 7 days. At 2-8 C Hepatitis B and
Syndrome and E viruses, jaundice syndrome In case of delay C rapid tests in
in transportation, districts. Anti-
2. Leptospira
store at -20C deep Hepatitis B and C
freezer. antibody detection
(ELISA) at PHL:
Acute Hepatitis B if
HBsAg or IgM anti-
HB core- positive
and Hepatitis C if
Anti-HCV positive.
Leptospirosis rapid
test at PHL.
7 Acute 1. Streptococcus A large cluster (>10 Sample collection Viruses suspected: Viruses Testing dependent
Respiratory pneumonia, cases) of ARI dependent on At 2-8C for 48 hrs. suspected: At on suspect culprit:
Infection (ARI) suspect culprit: In case of delay in 2-8C, swabs in multiplex testing
2. Respiratory syncytial
38
nasal, throat and/or transportation store VTM. Bacteria for viruses, culture
virus,
blood samples. at -70C. Bacteria suspected: for bacteria?

3. Parainfluenza virus, suspected: culture immediately in
isolates at -20 C. transport media
4. Influenza virus,
at 2-8 C.
5. Avian influenza virus,
6. Haemophilus influenza
B,
7. Legionella
pneumophila,
8. Yersinia pestis
A cluster* of ARI One nasal and At 2-8C for 48 hrs. At 2-8C, swabs Influenza testing
cases that require one throat swab In case of delay in in VTM by PCR/Real-
hospitalization (Severe samples from all transportation store at time PCR testing
Acute Respiratory SARI cases using -70C. at PHL. Send
Infection (SARI)) appropriate PPE. to Reference
Laboratory outside
the country if
necessary.
Unusual death(s) due to One nasal and At 2-8C for 48 hrs. At 2-8C, swabsInfluenza testing
ARI (e.g. in <60 years one throat swab In case of delay in in VTM by PCR/Real-
old) samples from all transportation store at time PCR testing
SARI cases using -70C. at PHL. Send
appropriate PPE. to Reference
Laboratory outside
the country if
necessary.
A single case of suspect One nasal and In a refrigerator of At 2-8C, swabs Influenza testing
avian influenza: a person one throat swab 2-8C for 5 days. in VTM by PCR/Real-
hospitalized with ARI samples from all In case of delay in time PCR testing
who during the past 7 suspected avian transportation, store at PHL. Send
days prior to onset of influenza cases in -70C deep freezer. to Reference
symptoms had exposure using appropriate Laboratory outside
to sick/dead birds PPE (within 72 the country if
OR living in a village hours of onset of necessary.
with confirmed avian fever)
influenza in birds OR
39
close contact (within one
meter) with a confirmed
human H5N1 case.
A single case of suspect Blood or sputum Culture isolates at Immediately in Isolation of

pneumonic plague: sample -20 C transport media Yersinia pestis
cough with blood at 2-8 C at reference
stained sputum, chest laboratory outside
pain, or difficult breathing Bhutan.
8 Dengue fever Dengue viruses type 1, A cluster* of suspect Blood sample At 2-8C for 7 days. At 2-8 C Dengue rapid
2, 3 and 4 dengue fever (after 5 In case of delay in test in endemic
days of onset of illness) transportation, store areas and dengue
at -20C deep freezer antibody detection
(ELISA) at PHL:
Detection of
dengue IgM /IgG
from serum or
demonstration of a
fourfold or greater
rise in reciprocal
IgG/IgM antibody
titres to one or
more dengue virus
antigens in paired
serum samples
40
9 Diphtheria Corynebacterium A cluster* of suspect Nasal swab, throat Culture isolates at Immediately in Isolation of
diphtheriae diphtheria swab and/or -20 C transport media Corynebacterium
pieces of pseudo- at 2-8 C diphtheriae from a
membrane clinical specimen.
10 Fever with Rash 1. Measles virus, A cluster* of fever with Sample collection Measles and rubella: At 2-8 C Testing strategy
rash dependent on see below. Dengue: dependent of
2. Rubella virus,
clinically suspect see above. Orientia clinically suspected
3. Dengue virus, culprit: blood or tsutsugamushi: culprit: Detection
stool sample/rectal Conserve at +4C. of measles and
4. Orientia
swab, throat and Enterovirus 71 and rubella-specific
tsutsugamushi,
vesicle swab Coxsackie virus A16: antibodies by
5. Enterovirus71, swab samples in ELISA. Detection
VTM of Orientia
6. Coxsackie virus A16
tsutsugamushi
and others,
by rapid test
7. group A streptococcus or PCR in the
bacteria, future. Isolation of
8. Other viruses Enterovirus 71 or
Coxsackie virus
A16 and PCR
testing.
A single case of suspect Blood sample In refrigerator of At 2-8 C Presence of
41
measles: Any persons 2-8C for 7 days. measles-specific
presenting with fever In case of delay in IgM antibodies in
AND maculopapular transportation, store serum (ELISA) at
rash AND any of the in -20C deep freezer. PHL.
following: cough, coryza
OR conjunctivitis
A single case of suspect Blood sample At 2-8C for 7 days. Immediately at Presence of
rubella: any person In case of delay 2-8C rubella-specific
presenting with fever in transportation, IgM antibodies in
AND maculopapular store at -20C deep serum (ELISA) at
rash AND cervical, freezer. PHL.
suboccipital or
postauricularadenopathy
or arthralgia/arthritis
11 Bacterial 1. Neisseria meningitidis, A single case of suspect Cerebrospinal Culture isolates at Immediately in Positive
Meningitis 2. Streptococcus bacterial meningitis fluid and/or blood -20 C transport media cerebrospinal fluid
pneumoniae, sample at 2-8 C culture or positive
3.Haemophilusinfluenzae blood culture.
B
12 Acute 1. Japanese encephalitis A cluster* of AES Blood sample and/ At 2-8C for 7 days. At 2-8 C Japanese
Encephalitis (JE) virus, or cerebrospinal In case of delay encephalitis (JE)
Syndrome (AES) fluid (CSF, when in transportation, virus:
2. Rabies virus,
possible) store at -20C deep Fourfold or
3. Other viruses freezer. greater rise in the
JE virus-specific
antibody in paired
sera (acute and
convalesent
phases) through
IgM /IgG, ELISA
42
Detection of the
JE virus or antigen
in blood by PCR
JE virus-specific
IgM in the CSF
13 Pertussis Bordetellapertussi A cluster* of suspect Nasopharyngeal Culture isolates at Immediately in Isolation of B.
pertussis specimen -20 C transport media pertussis from
at 2-8 C clinical specimens
14 Rabies (human) Rabies virus A single case of suspect Blood sample, CSF At -20 C if immediate Immediately at Test can be
rabies and/or saliva shipment is not 2-8C performed at
possible National Centre
for Animal Health.
Isolation of rabies
virus from clinical
specimens and
confirmation
of rabies viral
antigens by
direct fluorescent
antibody testing.
15 Congenital Rubella virus A single case of suspect Blood sample At 2-8C for 7 days. At 2-8 C Testing of serum
Rubella congenital rubella In case of delay in sample from the
Syndrome (CRS) syndrome transportation, store infant: Presence
at -20C deep freezer of rubella-specific
IgM in serum
(ELISA) at PHL.
16 Tetanus Clostridium tetani A single case of suspect No sample Not applicable Not applicable The diagnosis is
tetanus required! entirely clinical and
does not depend
A single case of suspect on bacteriological
neonatal tetanus confirmation.
17 Typhoid / Salmonella typhi / A cluster* of suspect Blood and/or stool Culture isolates at Immediately in Rapid tests in
Paratyphoid paratyphi typhoid/paratyphoid sample/rectal swab -20 C transport media hospitals. Isolation
fever fever at 2-8 C and culture
of Salmonella
typhi/ paratyphi
43
from blood or
stool needs to
be established
in-country or
testing agreement
with reference
laboratory outside
the country.
18 Unusual Biological, chemical or Any disease(s), death(s) Sample dependent Testing depends
Disease(s), radiological events or event that are on clinical on suspect culrpit.
Death(s) OR considered as unusual symptoms
Event by the health worker
Collection of samples from food, environment & zoonoses
Samples Suspected Pathogens/Toxins/ Amount to collect Storage Transportation To
Remarks
Chemicals (Min) confirm
Food, Actual or Bacteria: 100-500 g (collect 2-80C for Transport When
suspected food in 2 -3 batches as 24 hours. If immediately to possible food
Campylobacter,
desired) immediate the laboratory in sealed
Components or Salmonella, transportation at containers
ingredients of
Shigella, is not possible, or packets
suspected 2-80C.
Aeromonas, store at -20 to should
food Food -700C be sent
Listeria,
prepared under in original
similar conditions Yersinia, condition
Vibrio, without
Pathogenic E. coli (incl. opening.
VTEC),
44
B. cereus,
Staph. aureus,
C. perfringens
Virus testing:
Norovirus
Astrovirus
Rotavirus
Hepatitis A, E
Toxin testing:
Staph. aureus toxin
Chemical:
Histamine
Water Bacteria: 500mL(collect in 2 -3 2-80C for
Campylobacter, batches as desired) 24 hours. If
immediate
Salmonella,
transportation
Shigella, is not possible,
Aeromonas, store at -20 to
Listeria, -700C
Yersinia,
Vibrio,
pathogenic E. coli (incl.
VTEC),
B. cereus,
Staph. aureus,
C. perfringens
Virus testing:
Norovirus
45
Norovirus
Astrovirus
Rotavirus
Hepatitis A, E
Toxin testing:
Staph. aureus toxin
Chemical:
Histamine
Parasites:
Giardia lamblia,
Cryptosporidum
parvum
Swabs from Test for possible contamination 2-3 swabs each 2-80C for
potentially by microbes from suspected 24 hours. If
contaminated contaminated area immediate
transportation
Equipment/walls
is not possible,
& floors/ etc
store at -20 to
-700C
Zoonoses Consult National Centre for

Animal Health for advice on
collection, storage and transport
of samples from animal sources
46
Annexure 7
Example of prevention and control measures
Control Measures Examples

1. Control measures aimed at the outbreak source
Food, water or Closure of premises or site of outbreak Food premises closure
environmental
Modification of procedures Swimming pool filtration, chlorination
sources
Cleaning or disinfecting contaminated equipment or Cleaning water tanks, chlorination
fittings
Animal contact Removal from contact / Isolation Ban on the consumption of contaminated meat/ burial of dead animals
Treatment of animals Immunization of cattle to prevent human leptospirosis
Immunization Culling of poultry/ euthanize dogs in case of rabies
Destruction of animal reservoirs
47
Human sources Treatment of cases and carriers Treatment of all malaria cases and carriers
Exclusion or restriction of activities Temporary restrictions placed on food handlers or health care workers with gastroenteritis
symptoms
Isolation & Quarantine
Use of universal precautions to manage hospital in patients infected with or carrying MRSA
Education
People arriving in the country with viral hemorrhagic fever, close contacts of a confirmed
case of measles
Advising individuals with STIs to use condoms during sexual contact
2. Control measures aimed at contaminated vehicles and vectors

Contaminated Removal or recall of contaminated product Freeze/ban sale of all poultry products from the affected area.
food or water
Treatment, pasteurization or sterilization of contaminated material Use of boiled or treated water
Vectors Application of insecticides Indoor residual spray/fogging
Minimize human-vector contact Use of bed nets, screens, wearing long sleeved cloths and insect
repellents
Light traps to control housefly

Setting traps
Clearing clogged drains
Eliminating breeding habitats
Waste segregation / deep burial or decontamination of infectious waste
Improving management of solid waste
3. Examples of control measures aimed at susceptible humans
Food, water or Education to change behavior associated with food Education on hand washing, sanitation, implementation of a food safety measures
environmental preparation or hygiene
Issuing boil water notices
sources
Instructions to treat or sterilize contaminated material
Use of screens, bed nets, long-sleeved shirts and insect repellents to reduce risk of vector
Education to reduce contact with vectors borne disease
48
Human sources Administration of chemoprophylaxis Prophylaxis for close contacts of the index case in case of meningococcal disease
Immunization Immunoglobulin and vaccine for hepatitis B
Use of condoms to prevent STIs
Advice on physical barriers Correct malnutrition or vitamin deficiency to reduce the effects of measles
General improvement in host resistance

Annexure 8
Preparing a Report
All outbreaks must be documented in a scientific and systematic manner. While preparing a report
on the outbreak investigated, following points ought to be mentioned.
Title of the Report
E.g. Report on X outbreak in Thimphu Dzongkhag.
Summary:
Give a summary of 1-2 paragraphs which must contain overview of the investigation. A summary
should be able to answer WHO, WHAT, WHERE, WHEN, WHY/HOW about an outbreak and
should also contain about the causative agent in brief, causal hypothesis based on the evidence,
key recommendations, ongoing actions and pending/required actions.
Introduction/Background Information:
An introduction and background should describe about surveillance trends and similar outbreaks.
Include specific events that had let to the investigation and mention
- how the outbreak is reported
- steps taken to confirm the outbreak
- and who all were involved in investigating the outbreak
Describe about the area/site or the health facilities available in the place where the outbreak
occurred.
Aim and Objectives of Investigation:

Mention aim and objective for investigating an outbreak.
Methodology of Investigation:
As you write about your methods of investigation of an outbreak, you can break down your
methods of investigation into three main points as follows:
1) Epidemiologic
Define the cases and mention about how you ascertained an outbreak. Do not forget to mention
about your case study design.
2) Laboratory method
Under this heading you can mention about clinical and environmental sample collection. Write
where the samples were sent for analysis and types of analyses performed.
3) Environmental assessment
Mention about your visit to the site of the outbreak and risk assessment. You can also mention
about trace back of food products or other items.
49
Results of response and evidence of impact:

Mention your findings of the outbreaks. You can do it in the following format for easier understanding
and directness of the report.
1) Epidemiological findings
Mention about:
- The numbers of questionnaires sent and the numbers that you got it back.
- Number of cases and descriptive and the clinical data on cases
- Geographic distribution of the case
- Epidemic curve
- Risk factor analysis
- Attack rates by age, sex, exposure
2) Laboratory findings:
Mention about the laboratory findings; genotyping, culture results, etc.
3) Environmental findings
Write about results you got of risk assessments and any trace back investigation.
Discussion:
Under this heading you can discuss main hypothesis and justify conclusions and actions.
Also explain some of the actions to protect public health. Highlight any lessons learned when
investigating this case and include problems encountered (if any), errors committed, limitations of
the study, useful lessons for planning future investigations.
Conclusions:
Provide opinion(s) on nature of the illness, source of the outbreak, mode of transmission
Recommendations:
Include a statement on control measure for immediate control and control measure for future
prevention and also mention of specific obstacles, and shortcomings. The recommendations
should also include message to educate fellow Public health Professionals and inform policy
makers.
Attachment of supportive documents:
A report without supportive document is of little importance and it would mean lack of evidence
to those who study the report. Hence it is very important to attach all the supporting documents
necessary. Supporting document includes:
- Graphs and tables
- Inspection report
- test results, etc.
50
Annexure 9
CONTRIBUTORS
Mr. Sonam Wangchuk
Chief Laboratory Officer
Public Health Laboratory
Ministry of Health
Dr. Karma Lhazeen

Chief Program Officer
Communicable Disease Division
Ministry of Health
Dr. Sithar Dorjee

Regional Coordinator
One Health
Faculty of Nursing and Public Health
Dr. Kinzang Dukpa

Program Director
National Centre for Animal Health
Department of Livestock
Ministry of Agriculture and Forest
Dr. Tenzin
National Center for Animal Health
Ministry of Agriculture & Forest
Dr. Ratna B. Gurung

National Center for Animal Health
Ministry of Agriculture and Forest
51
Dr. Kinley Penjore

One Health Fellow
Dr. Tandin Zangpo

One Health Fellow
Dr. Kezang Dorji

One Health Fellow
Mr. Karchung Tshering

Senior Lab Officer
Ministry of Health
Mr. Tshering Dorji

Senior Lab Officer
Ministry of Health
Ms. Roma Karki

Program Officer
ARI Program
Ministry of Health
Mr. Kencho Wangdi

Program Officer
IHR Program
Ministry of Health
Mr. Rinzin Kinga Jamtsho

Program Officer
Zoonotic and AI Program
Ministry of Health
.
52

Outbreak Investigation Manual Final

Încărcat de

Informații document

Drepturi de autor

Formate disponibile

Partajați acest document

Partajați sau inserați document

Opțiuni de partajare

Vi se pare util acest document?

Este necorespunzător acest conținut?

Drepturi de autor:

Formate disponibile

Outbreak Investigation Manual Final

Încărcat de

Drepturi de autor:

Formate disponibile

DISEASE OUTBREAK INVESTIGATION

Cover design by:

(Dr. Pandup Tshering)

Scope of the manual

Law & Order

Definition of Rapid Response Team (RRT)

2.1. National Health Rapid Response Team (NHRRT)

Specific functions of each team of NHRRT:

2.2. Dzongkhag Health Rapid Response Team (DHRRT)

Specific functions of each team of DHRRT:

Definition of Excess of normal expectancy

Reasons for investigating an outbreak

Overview of Outbreak Investigation Steps

Step 1: Preparation for field work

Step 2: Confirm outbreak and diagnosis

Predetermined definition of an outbreak:

How to determine an outbreak

i. Indicator based surveillance

ii. Event based surveillance

iii. Self-reported cases of illness

Step 3: Define case and start case finding

Table No. 1: Example for the classification of cholera case definition

Case definition* Features

Identifying & Counting Cases

i. Common event outbreaks:

iii. Institutional outbreak:

Collect information about cases (Line listing):

Step 4: Describe the outbreak

Benefits of using Epi curve:-

Step 5: Develop Hypotheses

Step 6: Test Hypotheses

i. Compare your hypotheses with the established facts:

Step 7: Refine Hypotheses and carry out additional studies:

7.1. Laboratory Investigation:

Specimen collection, storage and transport

Interpretation of laboratory result

7.2. Environmental Investigation

Table No.3: Summary of environmental investigation*

Outbreak type Role of environmental investigation

Step 8: Implement control and prevention measures

Step 9: Communicate Findings

Step 10: Follow-up of implementation of control measures

Table No. 4: Summary of Outbreak Investigation Steps and Management

Step 2: Confirm outbreak Outbreak Detection: Routine surveillance DHO at district,

Step 4: Descriptive data Characterization of outbreak by person, Rapid response team

Step 5: Develop Development of hypothesis Rapid response team

Step 8: Implement control Implementation of control measures. Rapid response team,

Step 9: Communicate Incidence reports within one week of DHO at district,

COMMUNICATION DURING OUTBREAK INVESTIGATION

Use the following principles:

3. Communication with the Ministry of Health and PHL

4. Communication with other relevant agencies (National/international)\

Specific roles and responsibilities:

ii. District Health Officer:

iii. Medical Officer:

iv. BHU staff during outbreak

Outbreak line listing form:

Rapid Response Kit:

Example on how to draw epidemic curve:

The epidemic curve has the following format:

Interpreting the epidemic curve

The epidemic curve of a community-wide outbreak, with person-to-person spread, is likely to be

Calculate an incubation period:

Table 5: Sample case data for calculation of incubation period.