steps in investigation of an epidemic

1. Wish You a Very Good Morning

2. Seminar VII By
Dr.M.S.Bala Vidyadhar

3.  Introduction
 Historical Background
 Definitions
 Objectives of epidemic investigation
 Steps in Epidemic Investigation
 Recent Outbreaks & Measures around the World
 Conclusions
 References
 Previous Year References

4.  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.

6. 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

7.  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

8.  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.

9.  Index case: It refers to the first case to come to
the attention of the investigator.

10.  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

11.  Secondary Attack Rate
Number 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).

12.  Case fatality Rate
 It is the ratio/Proportion of deaths to cases of a
particular disease.
Total number of deaths due to
particular disease
CFR= X100
Total number of cases due to
same disease
 Case Fatality rate for Influenza was < 0.1% when treated.

13.  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.

14.  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

15. 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

16.  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.

17.  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.

18.  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.

20.  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%.”

21.  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.

22.  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.

23.  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.

24.  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.”

25. 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.

26. 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.

27.  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.

28.  (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.

29. 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.

30. 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.

31. Serial no. : Date:
Investigator :
Name of the person :
Age/sex :
Occupation :
Place of work :
Residential address :
H/o cholera vaccination within
1 year : yes/no
If yes date and place of vaccination: .
For previous 7 days
Place 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...

32. 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/no
History from patient
Whether suffering/cured:
Date and hour of onset of symptoms:
Clinical manifestations :
Nausea :
Vomiting : if yes number and day
Loose motion : if yes number and day
Blood/mucus in stool : yes or no
Sunken eyes Dry tongue
Muscular cramps Inelastic skin
Treatment received : Yes/no
If yes place : private doctor/VHG/MPW/MO/PHC
ORS/IV fluids given : Yes/no Details:
Contd...

33. Laboratory tests
Specimen Date of collection Results
Stool
Rectal swab
Vomitus
Food
Water for
chemical tests
bacteriological tests
Outcome of case:
Recovered/died
In case of death: Date and hour of death
If attended by MO: Yes/No

34. 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.

35. 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

36. 0
5
10
15
Time
1
Median onset time
2
3
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

37. Mean IP
0
5
10
15
20
1 4 7 10 13 16 19 22 25 28 31 34 37
No of cases
Weeks

38. 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

39. 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. 40
Original map by Dr. John Snow showing the clusters of Cholera cases
in the London epidemic of 1854

41. 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

42.  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

43.  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

44.  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

45.  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

46. 1. Background
 Geographical location
 Climatic conditions
 Demographic status (population pyramid)
 Socioeconomic situation
 Organization of health services
 Surveillance and early warning systems
 Normal disease prevalence

47. 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

48. 3. Methodology of investigations
 Case definition
 Questionnaire used in epidemiological investigation
 Survey teams
 Household survey
 Collection of laboratory specimens
 Laboratory techniques

49. 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

50.  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

51. 5. Control measures
 Definition of the strategies and methodology of
implementation
- constraints
- results
 Evaluation
- significance of results
- cost/effectiveness
 Preventive measures

52.  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.

53. 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.

55.  Given by:
GOVERNMENT OF INDIA
NATIONAL INSTITUTE OF COMMUNICABLE
DISEASES
(Directorate General of Health Services)
Ministry of Health & Family Welfare

59.  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

60.  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

61.  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.

64.  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.

65.  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.

66.  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.

67.  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.

70.  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.

71.  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.

73.  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.

74.  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.

75.  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.

78.  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.

79.  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.

81.  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.

82.  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.

83.  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.

84.  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.

85.  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

87.  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

92.  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

93.  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.

94.  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

95.  www.jmohlebo@dhs.ca.gov
 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

96.  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.