Guidelines for Management of Outbreak in Healthcare Organization Dr. NAHLA ABDEL KADERوMD, PhD. INFECTION CONTROL CONSULTANT, MOH INFECTION CONTROL CBAHI SURVEYOR Infection Control Director, KKH.

1. Kingdom of Saudi Arabia
Ministry of Health
General Directorate for Health Affairs – Najran
King Khalid Hospital
1

2. Introduction
2
An Outbreaks of HAIS infection should be identified
and promptly investigated because of their importance
in terms of morbidity, costs and institutional image.
Early identification of an outbreak is important to limit
transmission among patients by health care workers or
through contaminated materials.

3. An outbreak is defined AS
3
Occurrence of more cases of
disease than expected HAIs
outbreak-any group of illnesses
of common etiology occurring in
patients of a medical care facility
acquired by exposure of those
patients to the disease agent
while confined in such a facility.

4. Definition- (cont.)
4
Occurrence of more cases of disease
more than expected

over a particular period of ( TIME )

in a given area (PLACE )

among a specific group of people
(PERSONS)

5. Aim of this Guideline
5
1.Provide a management protocol of an outbreak
in health care facilities.
2.Early detection of an outbreak and institute
immediate control measures.
3.Assign roles and responsibilities of persons
involved in management of an outbreak.

6. Aim of Outbreak Investigation
6
1.Prevent further disease transmission
2. Provide information that can be used to
control the outbreak
3.Prevent similar occurrences in the future
4.Identify populations at risk of a disease
5.Identify modes of disease transmission

7. Aim of Outbreak Investigation, cont7
6. Evaluate the effectiveness of infection
control measures.
7. Learn more about a disease, including the
impact of control measures.
8. Share knowledge and findings with other
health professionals by documenting the
outbreak investigations in reports or journal
article

8. Steps Of An Outbreak Investigation
8
1.Verify the diagnosis; identify the agent
2.Confirm that an outbreak exists
3.Search for additional cases.
4.Characterize the cases by person, place, time.
5. Form a tentative hypothesis (best guess at the
time).
6. Institute preliminary control measures.
7. Test the hypothesis.
8. Refine the control measures.
9. Monitor and evaluate the control measures.
10. Prepare and disseminate a final report.

9. Planning of Outbreak Investigation
9
Notify the appropriate individuals and
departments in the institution of the problem;
Establish terms of reference for the
investigation.
This must include
 development of an outbreak team.
 Infection control must be part of the outbreak
team.

10. 1. Preparation
10
Investigation
 Scientific
knowledge
 Review literature
 Consult experts
 Sample questionnaires
 Supplies
 Consult with laboratory
 Equipment
 Laptop, camera etc.

11. 1-Verify the Diagnosis;
Identify the agent
11
Describe the initial magnitude of the
problem and what symptoms got the
facility's attention .
What diagnosis has been established?
What agent (bacterial, viral, other) has
been identified?

12. Establish a Case Definition.
12

Standard set of criteria for deciding whether an
individual should be classified as (case ) or non
(cases ) based on whether or not they meet the criteria
identified for outbreak

Includes clinical criteria and restrictions by
time, place and person.

Must be applied consistently and without bias to
all persons under investigation

13. Case Definition cont..
13
Classification

Definite (confirmed)


Probable


Laboratory confirmed
Typical clinical features without lab
confirmation
Possible (suspected)

Fewer of the typical clinical features

14. 2. Confirm that an Outbreak Exists
14
Use your case definition to find all cases
Based on your knowledge in #1, are the numbers of
cases above what is endemic (usually seen) in the
facility?
If yes, consider that an outbreak exists
Total number of cases .?
Do you have an outbreak?
If yes, proceed
If no, reasons why
report will made with justification why this case is not considered
an outbreak.

15. 3.Search for Additional Cases
15
Encourage immediate reporting of cases
(laboratory, physicians, and personnel).
Search for other cases by retrospective record
review, ADM , REFERAL ,lab reports, etc.
Total number of cases:
Date

16. 4.Characterize the Cases
16
by
Person - Place- Time.
Prepare
Line Listing
Draw Epidemic Curve

17. The Line List
17
It is an important tool in effective outbreak
management. collecting data that are.
CONSISTS -of
Rows and columns.
 Each Row represents a case
 Each column represents descriptive factors
or clinical details (i.e. date of birth, onset
date, symptoms

18. Epidemic Curves
18
•Epidemic curve plots the number of cases
on the –y- axis
• and time (in days or weeks or months)
on the -x- axis
•What time interval you use on the x axis
depends on the incubation period and the
time period over which cases are
distributed.

19. Epidemic Curves
19
What it tells you
 Mode



of transmission
 Propagated
 Common source
Timing of exposure
Course of exposure
Incubation Period

20. Epidemic Curves
)Common source: point exposure (e.g., salmonella
8
7
Cases
6
5
4
3
2
1
0
1
2
3
4
5
6
7
Days
8
9
10
11
20
12

21. Epidemic Curves
Propagated source: secondary and tertiary cases (e.g., hepatitis A)
10
9
8
Cases
7
6
5
4
3
2
1
0
1
2
3
4
5
6
7
8
9
10
11
12
Week
21

22. Estimating date of exposure
Maximum
incubation
days 21
9
8
7
Cases
Probable time of
exposure
10
6
5
4
3
Minimum incubation
2
days 14
1
0
1
3
5
7
9
11
13
15
17
19
21
23
25
27
29
Days
22

23. Develop Hypotheses(best guess at the time)
23
Hypotheses should address
Reservoir
Source of the agent
Mode of transmission (Vector or vehicle )
 Exposure that caused disease
Review data to determine common host
factors and exposures.

25. Implement Control /Prevention Measures
25
Implement control measures as soon as
possible if you know the source of an
outbreak.
Aim control measures at the specific agent,
source, or reservoir.
Aim control measures at the weak link in the
chain of infection. (mod of transmission )

26. Infection Chain
26

27. bacteria
PATIENT
virus
EQUPEMEN
TS
parasite
MEDICATIO
NS
fungus
SURFACES
CONTACT
(DIRECT,INDIRECT)
DROPLETS
AIRBORNE
The host is a
person who
becomes
infected after
exposure to an
infectious agent

28. Control Measure
28
Chain broken

29. Monitor and evaluate the control
measures..
29
 The control measures will vary depending on the
agent and mode of transmission
 but may include isolation procedures or
improvements in patient care Hand hygiene Cohorting
or environmental cleaning.
 In
some outbreaks, you would direct control
measures at reducing the susceptibility of the host.
Examples
 Immunization against rubella
 Malaria chemoprophylaxis for travelers.

30. Refine the control measures
30
 additional control measures may be added
if needed
 example
 Destroying contaminated foods . fluids
 An infectious staff or food handler could be
removed from the work and treated.
 Close
the unit

31. The Descriptive Analysis
31
This includes identifying a potential exposure
type ,source and route of infection for the outbreak .
and
testing this hypothesis using statistical methods.
Special epidemiologic studies may be needed

32. Analytic Epidemiology
32
 which allows you to test your hypotheses.
 Use rates to identify high-risk groups
Numerator = number of case
 Denominator = number of people at risk

The nature of the outbreak determines which of
these studies you will use.
 Cohort studies .
 Case-control studies

33. Cohort Studies
33
Small, well defined population
 Contact each attendee and ask a series of
questions
 Ill Vs not ill Look for source exposure.





Attack rate is high among those exposed
Attack rate is low among those not
exposed
Most of the cases were exposed.
Relative risk = mathematical measure of
association between exposure and
disease .

34. Case-Control Studies
34
Case-control



Population not well defined
Case patients and comparison group (controls)
questioned about exposure(s)
Compute measure of association = Odds Ratio
IS a mathematical measure of association
OR relationship between exposure and
disease
A case-control study is the most common approach
To test hypothesis .

35. Communication and Conclusion
35
During the investigation of an outbreak,
timely, up to date information must be
communicated
to
the
hospital
administration, public health authorities,
and, in some cases, to the public.
Based on all evidence and the results of
an outbreak investigation
A final report describing all aspects of the
investigation should be prepared.

36. Prepare and disseminate a final report
36
 A final report on the outbreak investigation
should: describe the outbreak interventions, and
effectiveness,
 summarize the contribution of each team
member participating in the investigation.
 should also make recommendations to
prevent future occurrence.
 Make the final report. as detailed as
possible.

37. Final Report
37
 should also be a written report that follows
the usual scientific format of
introduction
 background
 methods
results, discussion
 and recommendations.
By formally presenting recommendations, the
report provides a blueprint for action.

38. 38