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Transcript of investigation of an epidemic
Wish You a Very Good Morning
INVESTIGATION OF AN EPIDEMIC
Seminar VII By Dr.M.S.Bala Vidyadhar
Introduction
Historical Background
Definitions
Objectives of epidemic investigation
Steps in Epidemic Investigation
Recent Outbreaks & Measures around the World
Conclusions
References
Previous Year References
Contents
It is an emergency situation and provides opportunities to use
epidemiological knowledge for immediate control of disease.
Sometimes investigation is done after the epidemic has burnt out
or disease has resumed endemic level.
Cholera, food poisoning, influenza, malaria, chikungunya fever,
Hepatitis A and anthrax are extensively documented as causes of
epidemics.
The primary motivation of any epidemic investigation is to
control the spread of disease within the population at risk.
Introduction
Historical Background of Epidemics
ca. 75,000 - 100,000 Greece 429–426 BC
Known as Plague of Athens, because it was primarily in Athens.
unknown, similar to typhoid
ca. 40% of population Europe 541–542
Known as Plague of Justinian, due to the name of the Byzantine emperor in power at the time.
Bubonic plague
ca. 30% of population
Europe, Western Asia, Northern Africa
165–180
Known as Antonine Plague, due to the name of the Roman emperor in power at the time.
unknown, symptoms similar to smallpox
>>9,000 India, Germany 1881–1896 fifth cholera pandemic Cholera
>>800,000 Europe, Asia, Africa 1899–1923 sixth cholera pandemic Cholera
>>100,000 Asia, Europe 1816–1826 first cholera pandemic Cholera
>>100,000 Asia, Europe, North America 1829–1851 second cholera pandemic Cholera
>50,000 Balkans 1738 Great Plague of 1738 Plague
>50,000 Russia 1770–1772 Russian plague of 1770–1772 Plague
>30,000,000 Congo Basin 1960–present HIV/AIDS pandemic HIV/AIDS
Epidemic : The “unusual” occurrence in a community or
region of the disease, specific health related behavior or other
health related events clearly in excess of “expected
occurrence”.
Outbreak: It is used for a small, usually localized epidemic.
Endemic : The constant presence of a disease or infectious
agent within a given geographical area or population group,
without importation from outside. e.g. Hepatitis A, cholera
Definitions
Sporadic: The word sporadic means scattered about, cases occurs
irregularly, haphazardly & infrequently from time to time. e.g.,
polio, tetanus, herpes zoster.
Pandemic: An epidemic usually affecting a large proportion of the
population, occurring over a wide geographic area. e.g., HIV/
AIDS, Influenza.
Primary case: It refers to the first case of a communicable disease
introduced into the population unit being studied.
Definitions…
Index case: It refers to the first case to come to
the attention of the investigator.
Definitions…
Attack Rate : The number of new cases in a population at risk during specified time interval.
The number of new cases during
specified time interval. Attack rate= X 100 Total population at risk during the same interval
Influenza: annual global attack rate estimated at 5 – 10% in adults and 20 – 30% in children
Secondary Attack RateNumber of exposed persons developing the disease within the range of the incubation period following exposure to the primary case.
No. of exposed persons developing the disease with in the range of the I.P
SAR = X100 Total No. of exposed/susceptible contacts
Secondary cases were defined as household contacts with influenza like
illness (ILI) or laboratory-confirmed influenza A(H1N1)2009, occurring
at least one day after but within seven days following symptom onset in
the index case.
ILI developed in 231 of the 1,589 household contacts, a secondary attack
rate of 14.5% (95% confidence interval (CI): 12.9–16.4).
Case fatality Rate
It is the ratio/Proportion of deaths to cases of a particular disease.
Total number of deaths due to particular diseaseCFR= X100 Total number of cases due to same disease
Case Fatality rate for Influenza was < 0.1% when treated.
An epidemic investigation calls for inference as well as
description.
Frequently, epidemic investigations are called for after the peak
of the epidemic has occurred;
In such cases, the investigation is mainly retrospective.
However, in investigating an epidemic, it is desired to have an
orderly procedure or practical guidelines as outlined below
which are applicable for almost any epidemic study.
Epidemic Investigation
The objectives of an epidemic investigation are
a. To define the magnitude of the epidemic or outbreak
involvement in terms of time, place and person.
b. To determine particular conditions and factors responsible for
the occurrence of the epidemic.
c. To identify the causative agent, sources of infection, and
modes of transmission.
d. To make recommendations to prevent recurrence
Objectives Of Epidemic Investigation
1. Verification of diagnosis
2. Confirmation of the existence of an epidemic
3. Defining the population at risk
4. Rapid search for all cases and their characteristics
5. Data analysis
6. Formulation of hypothesis
7. Testing of hypothesis
8. Evaluation of ecological factors
9. Further investigation of population at risk
10. Writing the report
Steps in an epidemic investigation
First step in the investigation.
The report may be spurious due to misinterpretation of signs or
symptoms by public or health worker.
It is not necessary to examine all the cases.
A clinical examination of a sample of cases is sufficient.
Laboratory investigations wherever applicable, are most useful
to confirm the diagnosis but control measures should not be
delayed until laboratory results are available.
1. Verification of diagnosis
Confusion often made between food poisoning, cholera and
gastroenteritis.
All continuous fever cases may not be of typhoid fever even during an
epidemic of typhoid fever.
Simultaneous occurrence of different conditions can also be
confusing.
E.g. an outbreak of smallpox was reported in a village near Pune but
later the cases turned out to be scabies after verification of diagnosis.
It is necessary to establish objective criteria for labeling persons as
cases.
Verification of diagnosis…
Case definition:
Is needed to identify and count the cases in order to determine who
may be affected by the epidemic.
Components of the case definition may include information about
time and place of exposure, clinical signs & symptoms and lab
findings.
Suspect: A case with specific signs and symptoms during specific
period of time
Confirmed: A suspected case with laboratory confirmation.
Probable: A case which has unique clinical or preliminary lab test
results during that period.
It is a case definition for outbreak of viral hepatitis A in
Rohtak urban slums in sept 2000.
“Acute febrile illness with malaise, anorexia, followed by
jaundice, hepatomegaly and abdominal tenderness in the right
upper quadrant, increase in the ALT>8 times the normal and
serum bilirubin>2mg%.”
Case definition: Eg:
Done by comparing the number of cases with disease frequencies
during the same period of previous years.
In case of endemic diseases like cholera, typhoid hepatitis A, it is
expected that some cases (few hundreds) always present throughout
the year. So these diseases to be consider as epidemic several
hundreds or thousands of cases have to occur in India.
2. Confirmation of the existence of an epidemic
In case of yellow fever, bubonic plague and polio even a
single case will constitute an epidemic in India.
But in the US single case of cholera constitute epidemic.
Thus the number that constitute an epidemic vary from
place to place.
States or districts should establish criteria on the number of
cases that constitute an epidemic based on their local situation.
The criteria are:
A 25% increase in the number of cases reported as compared
to corresponding period of previous year. This may not, be
sufficiently sensitive in the year that follows an outbreak.
A 25% increase in the number of cases reported as compared
the average number of cases over last four non-epidemic
years for the corresponding period.
Confirmation of the existence of an epidemic (contd..)
Information may be collected from routine health service
records e.g. OPD registers, in-patient registers etc.
Information should be collected not only from modern
medicine practitioners but also from other systems.
“Over 96 cases of gastroenteritis were reported during period
of 6 days (from 17th Oct to 22nd Oct 98) in Ramorally village.”
Confirmation of the existence of an epidemic (contd..)
1. Obtaining the map of the area
It should contain information about natural landmarks, roads and
location of all dwelling units along each road.
The area may be divided into segments, using natural landmarks as
boundaries.
This is again divided into smaller sections. Within each section, the
dwelling units may be designated by numbers.
3. Defining the population at risk
2. Counting the population
By doing census by house to house visits. The composition should
be known by age and sex.
Eg: For population at risk. In case of food poisoning- those who ate
the food. In case of outbreak of cholera- those who were using
water from the suspected well.
3. Defining the population at risk
Surveillance:
It has been defined as "the continuous scrutiny of all aspects of
occurrence and spread of disease that are pertinent to effective
control“.
The ultimate objective of surveillance is prevention.
Surveillance, if properly pursued, can provide the health agencies
with an overall intelligence and disease-accounting capability.
Surveillance is an essential prerequisite to the rational design and
evaluation of any disease control programme.
4. Rapid search for all cases and their characteristics
(a) Individual surveillance : This is surveillance of infected persons
until they are no longer a significant risk to other individuals,
(b) Local population surveillance : e.g., surveillance of malaria,
(c) National population surveillance : e.g., surveillance of smallpox
after the disease has been eradicated,
(d) International surveillance : At the international level, the WHO
maintains surveillance of important diseases (e.g., influenza,
malaria, polio, etc.) and gives timely warning to all national
governments.
Surveillance may comprise
1. Medical survey
It should be carried out in the defined area to identify all
cases including those who have not sought medical care,
and those possibly exposed to risk.
By the administration of epidemiological case sheet.
4. Rapid search for all cases and their characteristics
2. Epidemiological case sheet
This should be carefully designed to collect relevant
information.
If the epidemic is large it may not be possible to examine
all the cases. In such cases random sample should be
examined.
4. Rapid search for all cases and their characteristics
Epidemiological case history-cholera/gastroenteritisSerial no. : Date:Investigator :Name of the person :Age/sex :Occupation :Place of work :Residential address :H/o cholera vaccination within1 year : yes/noIf yes date and place of vaccination: .
For previous 7 daysPlace visited :Places where food and drink was taken:Contact with similar cases :If yes name and places of person :h/o similar illness in the family :Water supply: Main source : piped/public well/private well/dug
well/bore well /other Occasional source :
Contd...
Is water supply disinfected? : yes/no If yes, method, name of person disinfecting and date of disinfection in last
7 days: Presence of houseflies : yes/noHistory from patientWhether suffering/cured:Date and hour of onset of symptoms:Clinical manifestations :Nausea :Vomiting : if yes number and dayLoose motion : if yes number and dayBlood/mucus in stool : yes or noSunken eyes Dry tongueMuscular cramps Inelastic skinTreatment received : Yes/noIf yes place : private doctor/VHG/MPW/MO/PHCORS/IV fluids given : Yes/no Details:
Contd...
Laboratory testsSpecimen Date of collection ResultsStoolRectal swabVomitusFoodWater for
chemical testsbacteriological tests
Outcome of case:Recovered/diedIn case of death: Date and hour of deathIf attended by MO: Yes/No
3. Searching for more cases
The patient is asked about the
similar cases at home, family,
neighborhood, school, work place
having an onset within the
incubation period of index case.
The search for new cases should be
carried out everyday till the area is
declared free of epidemic.
Rapid search for all cases and their characteristics (contd..)
It has to be done using the parameters – Time, Place And Person.
a. Time
Prepare a chronological distribution of dates of onset of cases
and construct an “epidemic curve”. An epidemic curve
suggests :
Pattern of spread
Magnitude
Outliers
Exposure and/or disease incubation period
5. Data analysis
Epidemic curve- Point source
0
5
10
15
Time
1 Median onset time
23
50% 50%Probable exposure time
Median incubation time
1 2 3 4 5 6 7 8 9 10 11 12 1314 15 16 17 18 19 20 21 22
No of cases
Continous source
Mean IP
0
5
10
15
20
1 4 7 10 13 16 19 22 25 28 31 34 37
No of cases
Weeks
Epidemic curve- Propagated
0
5
10
Time
No of cases
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22
Data analysis (contd..)b. Place
Prepare a ‘spot map’ of cases and if possible their relation to
the sources of infection e.g. water supply, air pollution,
foods eaten, occupation etc..
The map shows the boundaries and patterns of disease
distribution. Clustering of cases indicate a common source
of infection.
39
40
Original map by Dr. John Snow showing the clusters of Cholera cases in the London epidemic of 1854
Data analysis (contd..)c. Person
Analyze the data by age, sex, occupation and other possible risk
factors.
Determine the attack rates/case fatality rates.
The purpose of data analysis is
1. To determine modes of transmission and the source and the vehicle
of the agent, so that the most effective measures can be initiated.
2. To determine the risk factors for disease.
41
6. Formulation of hypothesis Hypothesis is a proposition or a tentative theory designed to
explain the observed distribution of the disease in terms of causal
association of the direct nature.
The hypothesis should explain the epidemic in terms of
1. Causative agent
2. The possible source
3. Possible modes of spread
4. The environmental factors which enabled
it to occur.
42
7. Testing of hypothesis All reasonable hypotheses need to be considered and weighed by
comparing the attack rates in various groups for those exposed and
those not exposed to the each suspected factor.
This will enable the epidemiologist to ascertain which hypotheses is
consistent with all the known facts.
Sometimes the hypothesis needed to be tested by the analytical study
design (case control study) to the statistical significance.
43
8. Evaluation of ecological factors An investigation of the circumstances involved should be carried out
to undertake appropriate measures to prevent further transmission of
the disease.
The ecological factors which have made the epidemic possible should
be investigated such as sanitary status of eating establishments,
breakdown in the water supply system, changes such as temperature,
humidity, and air pollution, population dynamics of insects and
animal reservoirs etc..
In case of water-borne transmission is suspected(gastroenteitis) a
sanitary survey of water supply system from source to consumer
should be done. 44
9. Further investigation of population at risk
Needed to obtain further information.
This may involve medical examination, screening tests,
examination of suspected food, feces or food samples,
biochemical studies, assessment of immunity status etc.
This will permit classification of all members as to
1. Exposure to specific potential vehicles
2. Whether ill or not
45
1. Background Geographical location
Climatic conditions
Demographic status (population pyramid)
Socioeconomic situation
Organization of health services
Surveillance and early warning systems
Normal disease prevalence
10. Writing the report
2. Historical data Previous occurrence of epidemics
- of the same disease
- locally or elsewhere
Occurrence of similar diseases
- in the same area
- in other areas
Discovery of the first cases of the present outbreak
Report…
3. Methodology of investigations Case definition
Questionnaire used in epidemiological investigation
Survey teams
Household survey
Collection of laboratory specimens
Laboratory techniques
Report…
4. Analysis of data Clinical data
- frequency of signs and symptoms- course of disease- differential diagnosis- sequelae or death rates
Epidemiological data- Mode of occurrence- In time- By place- By population groups
Report…
Modes of transmission- sources of infection- routes of excretion and portal of entry- factors influencing transmission
Laboratory data- isolation of agents- serological confirmation- significance of results
Interpretation of data- comprehensive picture of the outbreak- hypothesis as to the causes- formulation and testing of hypothesis by statistical analysis
Report…
5. Control measures Definition of the strategies and methodology of
implementation- constraints- results
Evaluation - significance of results
- cost/effectiveness Preventive measures
Report…
It may be necessary to implement temporary control
measures at the commencement of an epidemic on the basis
of known facts of the disease.
These measures may be modified or replaced in the light of
new knowledge acquired by the epidemic investigation.
Report…
a. Health Administrator/Manager: for planning and
implementation of control/ eradication strategies.
b. Clinician: to update clinical knowledge & make alterations in
case management & diagnostic methods.
c. Research: For clues & basis for further need oriented research
programmes.
d. General Population: for sense of security, health educational
tool and to develop confidence in the health care delivery
system.
Uses of Report writing:
Role of Government Agencies in Epidemic Outbreaks
Given by: GOVERNMENT OF INDIA
NATIONAL INSTITUTE OF COMMUNICABLE DISEASES
(Directorate General of Health Services)Ministry of Health & Family Welfare
Check-List for Central Rapid Response Team for Disease Outbreak Investigation
Recommended Preparatory Action
Recommended Preparatory Action
Role of NGO’s in Epidemic Outbreaks
Complex emergencies require rapid and coordinated response in
order to deliver essential services to the affected population and
reduce the likelihood of increase in morbitiy, mortality and outbreaks.
NGOs can be local or international and they play a crucial roll in
delivering various forms of services in complex emergencies. They
vary greatly in terms of financial, technical and operational capacities.
Local NGOs with their limited resources but great knowledge of local
situation can have as much or greater impact in terms of delivering
services to displaced populations
Role of NGO’s
NGOs have other strengths that make them ideal actors in
emergencies.
These strengths include:
1. Ability to respond fast
2. Flexibility
3. Manoeuvrability
4. Creating public awareness
Strengths of NGOs as actors in complex emergencies
Some of the key public health services provided by NGOs in
emergencies include:
1. Curative services
2. Assist in disease surveillance.
3. Vector control.
4. Training and health education.
5. Water and sanitation.
NGOs and health service delivery in complex emergencies
Recent Outbreaks & Measures around the World
The most widespread epidemic of Ebola virus disease (commonly
known as "Ebola") in history is currently ongoing in two West
African countries.
It has caused significant mortality, with reported case fatality rates of
up to 70% and specifically 57–59% among hospitalized patients.
The outbreak began in Guinea in December 2013 and then spread
to Liberia and Sierra Leone.
On 8 August 2014, the World Health Organization declared the
outbreak a public health emergency of international concern.
2014 – Ebola in West Africa
On 31 July 2015, the WHO announced "an extremely promising
development" in the search for an effective vaccine for Ebola
disease.
While the vaccine up to now shows 100% efficacy in
individuals, more conclusive evidence is needed on its capacity
to protect populations through herd immunity.
Ebola outbreak…
As the epidemic appeared to be coming to an end in August 2015, the
WHO held a meeting to work out a "Comprehensive Care Plan for Ebola
Survivors" and identify research needed to optimize clinical care and
social well-being.
Saying "the Ebola outbreak has decimated families, health systems,
economies, and social structures", the WHO called the aftermath "an
emergency within an emergency."
Of special concern is recent research that shows some Ebola survivors
experience so-called Post-Ebola Syndrome, with symptoms so severe that
survivors may require medical care for months and even years.
Ebola outbreak…
Parts of Eastern India are still reeling under a sudden spurt of
Encephalitis cases. India’s Health Minister, Dr.Harsh Vardhan said
that more than 100 children in Bihar state have succumbed to the
virus this season.
India has faced annual outbreaks of Encephalitis with 500-600
people, mostly young children, dying in the northern state of Uttar
Pradesh.
This year over 100 people have died in West Bengal.
2014 – Encephalitis in India
Health experts say 70 million children are at risk across
India. Japanese Encephalitis can be prevented by vaccination and the
use of mosquito control measures.
India launched an indigenously developed vaccine, JENVAC, for
Japanese Encephalitis in 2013.
Japanese Encephalitis is found in most Asian countries, where it is
endemic in the rainy season.
It is also found in areas where flood irrigation is common. Over
three billion people live in areas where Japanese Encephalitis is
endemic.
2014 – Encephalitis in India
Middle East Respiratory Syndrome (MERS), a newly emerged viral disease, was first detected among travellers to the Middle East in 2012.
Countries where MERS cases have been identified are: Lebanon, Jordan, Kuwait, Oman, Qatar, Saudi Arabia, the United Arab Emirates, and Yemen.
MERS is caused by a corona virus that results in the rapid development of a severe respiratory disease. If a person already has an underlying respiratory condition, the disease is particularly severe.
2012 – Middle East Respiratory Syndrome (MERS) in the Middle East
In Pakistan in 2011, over 14,000 people were infected with Dengue fever
and over 350 people died due to this viral disease.
Most of the outbreaks were concentrated in and around Lahore, in Punjab
province, in Pakistan.
There have been at least a dozen major Dengue outbreaks around the world
since the year 2000.
There are 5 types of the Dengue virus, but an infection with one does not
grant immunity to the others.
2011-till date – Dengue Fever in Pakistan
The Dengue epidemic continues till date in Pakistan, though
the government and medical charities are fighting the disease
with the support of international medical bodies.
2011-till date – Dengue Fever in Pakistan
The year 2009-2010 witnessed a global flu pandemic as a new versions of
the H1N1 influenza virus emerged and affected people worldwide. This was
the second global flu pandemic after 1918.
A combination of bird flu, swine flu, and human flu viruses combined with a
European Pig Flu virus led to the disease being known as Swine Flu.
Subsequently in June 2009, both the WHO and the US Centers for Disease
Control stopped recording count of new cases and the outbreak was declared
a pandemic. The disease was labelled Swine Flu by the American media,
whereas the WHO refers to it as pandemic H1N1/09 virus.
2009-2010 – Flu / Swine Flu worldwide
The H1N1 pandemic was declared ended on 10 August 2010 by the
then Director-General of the WHO, Margaret Chan.
According to the WHO, more than 18,000 people died worldwide
since H1N1 emerged in April 2009.
However, other research has shown that the global death toll was
much higher since many cases were unreported, particularly in Asia.
Revised estimates show that as many as 284,500 people were killed
by the H1N1 pandemic.
2009-2010 – Flu / Swine Flu worldwide
2015 Indian swine flu outbreak refers to a outbreak of the 2009 pandemic
H1N1 virus in India, which is still ongoing as of March 2015.
The states of Gujarat and Rajasthan are the worst affected.
India had reported 937 cases and 218 deaths from swine flu in the year
2014.
By mid-February 2015, the reported cases and deaths in 2015 had
surpassed the previous numbers.
The total number of laboratory confirmed cases crossed 33000 mark with
death of more than 2000 people.
2015 Indian Swine Flu outbreak
The H1N1 virus outbreak had previously occurred India during the 2009 flu pandemic.
The virus killed 981 people in 2009 and 1763 in 2010. The mortality decreased in 2011 to 75. It claimed 405 lives in 2012 and 699 lives in 2013. In 2014, a total of 218 people died from the H1N1 flu, India recorded
837 laboratory confirmed cases in the year. Every year, there was a rise in number of cases and deaths during
winter as temperature affects virus. During 2014–15 winter, there was a spurt in cases at the end 2014. In 2015, the outbreak became widespread through India. On 12 February 2015, Rajasthan declared an epidemic.
2015 Indian Swine Flu outbreak-Background
On 13 February 2015, the Health Ministry began the procurement
process of 60,000 units of Oseltamivir (Tamiflu) and 10,000 units of
N-95 masks.
A tender for 10,000 diagnostic kits was floated.
The Health Ministry on 18 February 2015 said in a press release that
there was no shortage of drugs or logistics problems.
By 22 February 2015, more than 13688 had been infected and death
toll was reported to be 812 in the year 2015.
2015 Indian Swine Flu outbreak- measures
2014 Odisha jaundice outbreak (initially known as the 2014 Sambalpur
jaundice outbreak) refers to an outbreak of mainly Hepatitis E and
also Hepatitis A which began in the town of Sambalpur in Odisha, India.
The cause of the outbreak was suspected to be the contamination to drinking
water supplied by the Public Health Engineering Department (PHED).
By February 2015, it had spread and cases were being reported from Bolangir
district near Sambalpur, and some coastal districts like Cuttack,
Khurda and Jajpur.
The epidemic is still to be brought under control as of February 2015.
2014 Odisha jaundice outbreak
By 16 February 2015, the state had declared the districts Sambalpur,
Bolangir, Cuttack, Khurda, and Jajpur as jaundice affected.
By now Sambalpur had reported 2,945 and Cuttack had reported 116
cases, with there being total 3,966 cases from the state.
The official death toll was 36 but unofficially it was estimated to be
50.
A separate ward was set up in Shri Ramachandra Bhanj Medical
College, Cuttack to treat the victims.
2014 Odisha jaundice outbreak
The 2009 Gujarat hepatitis B outbreak was a cluster of Hepatitis
B cases that appeared in Modasa, northern Gujarat, India in 2009.
Over 125 people were infected and up to 49 people died.
Several doctors were investigated and arrested after the outbreaks.
The doctors were accused of re-using syringes, which had been
contaminated with hepatitis B virus, to treat other patients. Eight
medical practitioners were arrested under the Indian Penal
Code for culpable homicide not amounting to murder after allegedly
re-using infected syringes
2009 Gujarat hepatitis outbreak
224 medical teams, including some from All Indian Institute of
Medical Sciences and National Institute of Virology have set up
camps in Modasa, and remained there for at a month.
According to the officials 25,000 vaccines were sent to the most
affected area and 600,000 more vaccines are being arranged from
Hyderabad.
In addition, the government distributed 30,000 pamphlets and
mounted a campaign to inform residents about the disease.
The Health Department of the Gujarat government have sent 600,000
doses of vaccine to the area.2
2009 Gujarat hepatitis outbreak
Conclusions Essential function of public health professionals
Opportunity to gain new knowledge of diseases and to discover the
weaknesses of the current public health practices and systems
The world today is especially prone to epidemics or outbreaks
because of rapid urbanization, migration of the people, poor sanitary
conditions, tourism etc..
92
Co-ordination between district health authority, public health and
engineering, ICDS sector, medical college, media and people is
needed during investigation.
Circulation of the report is necessary to spread the information so
that no such episodes occur in other areas in future.
Conclusions
References K.Park, Park’s Text Book of preventive and social Medicine., 20th
edition.
P.V.Sathe and A.P.Sathe, Text book of Epidemiology and management
for health care for all, 2nd edition.
Sunderlal et al, Text book of community medicine, first edition, 2007.
Notes on surveillance, preventive and communicable disease,
directorate of health and family welfare services. Government of
Karnataka; January 2004.
Oxford text book of Public health, 4th edition,2002.
94
http://www.mapsofworld.com/around-the-world/recent-epidemic-outbreaks.html
https://en.wikipedia.org/wiki/2015_Indian_swine_flu_outbreak
https://en.wikipedia.org/wiki/Ebola_virus_epidemic_in_West_Africa
https://en.wikipedia.org/wiki/2014_Odisha_jaundice_outbreak
https://en.wikipedia.org/wiki/2009_Gujarat_hepatitis_outbreak
https://en.wikipedia.org/wiki/List_of_epidemics
References
Importance of Time Place & Person in Epidemiology:
RGUHS May 2007- 10 mks
Major Epidemic Outbreaks since last 10 years & measures
taken at Public & Private Sector for the same: Saveetha
University: March 2011-10 mks.
Steps in Outbreak Investigation & its Epidemiology:
Sumandeep University: December 2009- 20 mks.
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