EPI 201 FINAL EXAM STUDY GUIDE

What is an Outbreak?
Outbreak​: the occurrence of more cases of disease than what would normally be expected in a
given amount of time
Describe in terms of PERSON, PLACE, and TIME
Epidemic​: same as outbreak, but on a large scale
Pandemic​: same as epidemic, but on a GLOBAL scale
Endemic​: the constant presence of disease, stays at predicted level
Sporadic​: no pattern, appears randomly
Cluster​: cases that are grouped in a place/time that are suspected to be greater than the number
expected

Why do Outbreaks Occur?

Epidemiology: ​study of how and why diseases occur in groups of people
Host​: A human or animal that can be infected by an infectious agent
Host Factors: age, sex, culture, behavior, nutritional status
Environmental Factors: ​Enable disease transmission through the environment
Examples: pollution, climate, land, sanitation, housing, water , food
Agents: ​Include biological, chemical and physical
Outbreaks occur when host, agent, and environmental factors are not in balance, and they favor
the agent
Risk Factor: ​any characteristic or exposure of an individual that increases the likelihood of them
developing disease or injury

Factors in Outbreaks
Individual: ​Poverty,education, literacy, nutrition status, income, social status
Structural: ​politics, conflict, access to healthcare, inequality (POLITICS)
Physical Environment: ​urban growth, crowding, migration, housing location, sanitation,
pollution, access to nutrition
Social Environment: ​cultural values, social networks, community and social cohesion

Disease Occurrence
Types of Agents:
Bacteria: ​single cell organisms, are alive, harmful OR useful to humans
Viruses: ​can infect ALL living things, not alive, ALWAYS harmful
Parasites: ​encompasses protozoa, are alive, harmful OR useful
Funghi, Prion Disease: ​mad cow
Reservoir: ​the habitat in which the agent normally lives, grows, and multiplies
Susceptible Host: ​an individual not possessing sufficient immunity against a particular
infectious agent to prevent contracting an infection when exposed to infections.
Direct Transmission: ​spread through direct contact with other people, and droplet spread
Indirect Transmission: ​spread through air, food, water, soil, vectors, and fomites
Portal of Entry: ​how an agent enters a host
Examples: eyes, nose, mouth, skin, placenta, vaginal tract, anus
Portals of Exit: ​blood, saliva, feces
Infectivity: ​capacity of agent to enter/multiply in susceptible host.
Pathogenicity: ​the ability of the agent to CAUSE DISEASE in infected host
Virulence: ​measure of severity of disease
Infection vs. Disease: ​infection occurs when the agent first enters the host, while disease occurs
when the host begins to experience signs and symptoms
R_0 :​ Basic Reproductive Number
The number of new cases that an existing infected individual can infect
= new cases / original # of people infected
Incubation Period: ​the length of time between exposure and onset of symptoms
Period of Communicability: ​time during which an infected host can transmit an infection (are
contagious)
Chain of Infection:
1. Stage of Susceptibility: Exposure
2. Stage of Subclinical Disease: Time after exposure/incubation period
3. Stage of Clinical Disease: infection becomes apparent, start experiencing symptoms
4. Stage of Recovery, Disability, or Death
Vectors: ​organisms that transmit pathogens and parasites from one infected host to another
Vehicle: ​a non-living intermediary, such as food/water/biologic product that conveys the
infectious agent from its reservoir to a susceptible host

Outbreak Surveillance
Infectious Disease Surveillance: ​the systematic, ongoing, collection, analysis, interpretation,
and dissemination of data for public health action
Systematic: consistent over place and time
Analysis: descriptive epidemiology- PERSON, PLACE, TIME
Interpretation: True increase/decrease in disease- not just changes in reporting
Characteristics of Surveillance Systems:
Timeliness: how long it takes for a case to be recognized by surveillance
Representativeness: how detected cases compare to all cases of condition
Sensitivity: ​correctly identify those as sick, as sick
Specificity: ​correctly identify all those as healthy, as healthy
Case Definition: ​uniformly applied criteria for determining whether a person is a case of that
particular disease
Includes: PERSON, PLACE, and TIME
Case: an occurrence of a specific disease
Cluster: several confirmed cases of disease that occur over a similar time period/place
Outbreak case definitions are either: SUSPECTED, PROBABLE, or CONFIRMED
Pyramid of Surveillance: ​more people experience illness than those that get confirmed
diagnosis: We miss A LOT of cases along the way
1. Person has symptoms
2. Person goes to doctor
3. Doctor requests sample
4. Sample submitted to lab
5. Lab identifies the agent
6. Case Reported: This is what our surveillance data covers
Universal: ​choose entire population to monitor the condition of interest: Nationwide, Statewide
Sentinel: ​choose key location to monitor for condition
Examples: Hospitals, health providers, select cities/states
Passive Surveillance: ​rely on health care providers/labs to report cases of disease
Most surveillance systems are passive
Active Surveillance: ​periodic solicitation of case reports from reporting sources on a frequent
timeline

Methods of Surveillance
No Formal Surveillance: ​resource limited settings, and happens during an emerging pathogen
Syndromic Surveillance: ​Based on syndromes (signs and symptoms that may suggest a
common diagnosis)
Identify illness clusters early, before diagnosis is confirmed/reported
Data Sources: Emergency room visits, school/work absenteeism
Not completely accurate: will expect a lot of false positives
Lab Based Surveillance: ​clinical labs are key sources of isolates- routinely send reports to
reference labs
Clinical labs support the diagnosis of individual patients
Helps detect outbreaks, and determines the agent
Reporting delays because resource intensive
Integrated Lab-Based Surveillance: ​Integration of human (host), animal (reservoir), and
environmental surveillance
Very accurate: high sensitivity and specificity
VERY resource intensive
Outbreak Investigation
1. Prepare for Field Work: gather appropriate knowledge/equipment
2. Establish the Existence of an Outbreak: more cases than expected?
3. Verify the Diagnosis; send samples to the lab
4. Define a Case and Conduct Case Finding:
a. Case Definition: a standard set of criteria used to determine if a person has the
disease in question
b. Case Finding: contact tracing: reconstruct all the contacts of 1 case
5. Perform Descriptive Epidemiology: identify PERSON, PLACE and TIME
6. Develop Hypothesis
7. Implement Control and Prevention Measures
a. Contact Tracing
b. Isolation: separation of those who are known to have a contagious disease
c. Quarantine: separation of those who have been exposed to disease, but may or
may not develop disease
8. Initiate or Maintain Surveillance
a. Produce epidemic curves
9. Communication: education, messaging campaigns targeting spread

Outbreak Measurement
Ratio: ​one number divided by another: A/B
Proportion: ​one number divided by another: A/(A+B)
Rate: ​a measure of the frequency with which an event occurs - includes measure of time
Probability: ​the likelihood that something will happen
Outcome of interest / total # of possibilities
Prevalence: ​the measure of the number of currently ill of a specific disease in a population
Snapshot at that time of how many people are ill
# of cases / susceptible population
Incidence: ​number of new cases / number of people at risk - during some time period
Prevalence = ( Incidence ) ( Duration )
Mortality: ​# of deaths/ # of people at risk - during some time period
Attack Rate: ​used to estimate how fast an infectious agent is moving through a population
= # of new cases / # of people at risk
Case Fatality: ​ # of deaths from disease in population / total # of cases in population
Infant Mortality: ​# of infant deaths / # of live births
Relative Risk/ Risk Ratio/ Attack Rate Ratio
= (a/a+b) / (c/c+d) = the # of times more likely of getting disease if they were exposed
If RR >1 , exposure lead to disease. If RR = 1, null. If RR < 1, exposure is protective
 Horizontal= Sick? Yes No
Vertical= Exposed?

Yes a b

No c d

Patterns of Outbreak Source and Occurrence:

Epidemic Curve: ​a graphical way to show the distribution of cases by TIME OF ONSET
1. Common Source Outbreaks:​ all cases arise from a shared source (food, water, factory)
a. Point Source​: all cases appear in 1 incubation period, with no index case
b. Continuing Source: ​exposure is longer than point source, no index case
c. Intermittent: ​outbreaks come and go (seasonal)
2. Person to Person Spread: ​diseases spreads through direct/indirect transmission-
controlling source is no longer enough to stop transmission
a. Index Case with Limited Spread: ​1 index case, incubation period, others show
symptoms
i. Control through quarantine
b. Propagated Spread: ​Index case, incubation period, small outbreak, incubation
period, larger outbreak
i. People get sick mostly from secondary cases (since primary case = index)
Median of Incubation Period = ​midpoint incubation time in the case frequency distribution

HIV/AIDS Case Study:

Started seeing Kaposi Sarcoma a rare cancer affecting people with weakened immune systems
Created a narrow case definition: GRID- gay related Immune Deficiency
Gay men, under 60, in large metropolitan areas
Thought it was caused by a drug: poppers - used by many gay men
Started seeing cases in injection drug users, hemophiliacs, and Haitian Immigrants
Started calling it AIDS
Affected 4H risk groups: Heroin Users, Haitians, Hemophiliacs, and Homosexual Men
Started to see mother-child transmission
Implemented Control Measures​: avoid sexual contact with people with AIDS, high risk groups
can’t donate blood, safer blood products needed to be developed
AIDS in Africa: ​symptoms looked similar to endemic diseases- also, role of migration, conflict,
and trade in the spread of AIDS

Outbreak Preparedness, Response and Management:

Local public health agencies are CENTRAL to epidemics (all outbreaks are local)
Launching an Investigation
1. Communicate! : ​inform neighboring public health departments, state, Centers for
Disease Control and Prevention, and the community
2. Gather Resources: ​laboratory needs, personnel, and budget.
Incident: ​anything out of the ordinary day to day activities that necessitates a response
National Incident Management System (NIMS) - ​used in outbreaks of every size
Incident Command System: ​flexible/can respond to range of events and needs
Enables most competent person to be in charge
Promotes all responders to work together for best results
Unified command with common terminology
Create “Incident Action Plans” - can be planned before events/mass gatherings
Incident Commander: ​highest ranking first responder
Local Health Officer: ​smallest unit of public health, but has the greatest power during outbreak
situation: can close businesses, quarantine, and isolate people during outbreaks
Incident Command System: ​DOD sends troops to help in outbreak situations
City Readiness Initiative: ​large scale mass drug dispensing programs
Dispense antibiotics and other pharmaceuticals to urban populations within 48 hours
Points of Distribution (PODS) - ​timing, planning/practice, triage, epi investigations, health
services, prevention
Triage a large number of people in a short amount of time
Where you go for vaccinations

Control, Elimination, and Eradication

Controlled Disease: ​ incidence has been greatly reduced in an area due to public health
intervention
Eliminated Disease: a ​disease that is completely gone from a specific geographic region
Eradicated Disease: ​a disease that is completely gone from the world (except in labs)
Emerging Infectious Disease: ​disease new to an area, and is increasing within the population

Risk Communication
Sharing information strategically about an issue to help people cope, make informed decisions,
understand sensitive issues, and not panic!
Perception of Risk = Actual Hazard + Level of Outrage
SOCO- Your Key Message​ : less than 100 words, provide 3 most important facts, identify
primary and secondary audience
7 C’s of Public Health Communications
1. Command Attention
2. Clarify the Message
3. Communicate a Benefit
 4. Consistency Counts
5. Cater to the HEART and the HEAD
6. Create Trust
7. Call to Action

Mathematical Models:
SIR: Susceptible-Infected-Recovered Models : ​people infected can infect healthy, but some
are recovered/immune
Elements= “actors” in model- usually people or animals
States= attributes of elements: susceptible, infected or recovered
Constant Growth Model: One person infected every time step
Proportional Growth Model: exponential growth of infected people

One Health:
Integrates human and animal surveillance to identify and predict possible spillover events
(Passive Surveillance)
Conduct Surveillance on animal populations and extrapolate it to help with humans
Zoonosis: ​disease transmitted from animals to humans
Enzootic: ​the animal version of endemic
Epizootic: ​the animal version of epidemic
Reverse Zoonosis: ​transmitted from humans to animals
Drivers of Zoonotic Disease Emergence:
Major Changes in human population growth, climate change, and travel
Increased human-wildlife contact, land use changes,
Animal intensification- farm animals in small spaces

Outbreak Prevention
Reduce disease by targeting different parts of the epidemiological triangle
Host:​ ​Conduct Screening/Testing
Screening: ​prevention or effective treatment
Do it to a large number of people without signs of disease
Do it to detect potential for disease indicators
Testing: ​treatment
Small number of symptomatic individuals
Do it to confirm presence (or absence) of disease
Harm Reduction:
Safe injecting practices
Referrals for HIV testing services
Condom provision
Directly Observed Therapy
Healthcare worker observes patients taking medications
Reduces treatment failure and relapse
Patient stops being able to infect susceptible contacts
Vaccines
Herd Immunity: we can eliminate a disease without vaccinating everyone because if a majority
are immunized, those that opt-out will be safe
Risk: potential side-effects of vaccine,
Availability/Cost?
Environment:
Reservoir Control: ​vaccinate potential animals reservoir hosts
Vector Control: ​eliminate mosquito breeding grounds, urban spraying of insecticide
Environmental Remediation: ​disinfect and decontaminate ALL fomites
Hospital Acquired Infections: ​lots of tubes providing direct tract into body, easily allowing
infection to occur
Structural Level
Policy Change:​ change national standards, protection host from agent
Food policies- have a mandatory meat cooking temperature, screen cattle
Limit exemptions for vaccines like Measles
Social/Cultural Level
Mobilizing social networks: educate, reminders for meds

Panel Notes:
Measles Outbreak in Clark County:
Was resource intensive: did contact tracing, isolation
State of Emergency was declared so WA could bring teams in from other states
Clark County senatore introduced/passed legislation requiring vaccination against
measles in school children
Salmonella Outbreak
3 clusters in King County: 2 grad parties, and 1 BBQ
First thought it was tied to an ethnic dish
Dozens of clusters later: all tied to pig roasts
Took 100 cases before they issued a recall
Ebola Outbreak
Liberia- stressful, public distrust, no developed vaccine
Were conducting vaccine research during this time
Vaccination
Lack of vaccination roots from lack of access, fear of oppressive government
Map out where vaccinated people are, target messages to these communities
Manage Economics: vaccines can save money in the long run- don’t have to pay for hospital
treatments if vaccinated!!
Climate Change = BIGGEST PUBLIC HEALTH CHALLENGE