Outbreak Investigation

Outbreak: Tell-Tale Signs,
Investigations, Actions & Solutions
SILVEROSE ANN A. ANDALES-BACOLCOL, M.D.,
FPCP, FPSMID
Internal Medicine and Infectious Diseases

OUTLINE of this LECTURE:
I. Definition of terms
II. How outbreaks are recognized
III. Reasons for investigating outbreaks
IV. Constraints of outbreak investigation
V. Infection Control Measures
VI. Preparing for the Investigation
VII. Steps in conducting an outbreak
investigation in health care facilities
VIII. Case Study

A. What is an outbreak?
 An incident in which two or more people who
are thought to have a common exposure
experience a similar illness or proven
infection.
 The occurrence of more cases of a disease
than expected:
 in a given place
 among a specific group of people or
population
 in a particular period of time

B. Epidemic
- same as outbreak but more widespread or
prolonged
C. Healthcare-associated infections
- are infections that occur in patients or healthcare
workers as a result of healthcare interventions
D. Hospital-acquired infections
- Infections acquired during hospital stay which were
not incubating at the time of admission

E. Health Care Facilities
- Hospital
- Private physician’s office
- Outpatient clinic
- Dialysis centers
- Ambulatory surgery
- Endoscopy units
- Long term care facilities
- Nursing homes
- Rehabilitation centers
- Institutions for mentally or
physically handicapped

II. How are outbreaks recognized?
A. By the clinician, infection control
professional, nurse, or medical staff
B. By the laboratory personnel or
microbiologist
C. By the patient or patient’s family
D. Hospital or healthcare-associated
infection routine surveillance data
E. Unusual agent, site or host

When to Consider Nosocomial Transmission
of Infectious Diseases?
 A cluster of similar infections occurs on one hospital
unit or among similar patients
 A cluster of infections associated with invasive devices
occurs
 HCWs and patients develop the same type of infection
 A cluster of infections with organisms typically
associated with hospital-acquired infections (MDR or
opportunistic organisms)

Determine Risk Factors for Disease or
Nosocomial Infection
 Host risk factors for HAI
 Invasive devices
 Severity of illness
 Underlying diseases (Malignancy, HIV)
 New technology (Chemo agents)
 Environmental risk factors
 Location (ICU vs. Ward)

III. Reasons for investigating outbreaks
A. Prevent additional cases in the current outbreak
B. Prevent future outbreaks
C. Assess prevention interventions
D. Learn about a new disease
E. Learn something new about an old disease
• New sources
• Unusual modes of transmission
• Complications of new procedures
F. Reassure the public
G. Minimize economic and social disruption

Negative Effects of Outbreaks
Outbreaks cause
 Morbidity, mortality
 Prolongation of stay
 Additional procedures
 Increases cost
 Bad reputation

IV. Constraints of Outbreak Investigation
A. Urgency to find source and prevent
cases
B. Pressure for rapid conclusions
C. Pressures because of legal and
financial liability
D. Delays can limit human/
environmental samples for testing

V. Infection Control Measures
 Introduce preventive interventions before
initiating or completing an investigation.
 Handwashing in-service sessions
 Close a unit to new admissions
 Remove a product or device
 Carefully weigh the potential benefit of more
drastic measures against the potential harm to
patients currently residing in the facility

 All levels of the health care facility’s personnel
must be committed.
 Hospital Administration
 Infection Control Unit
 Chief of the affected service
 Head Nurse or Supervisor
 Head of Microbiology
 Health care professionals (Doctors, nurses)

 Consider availability of microbiologic isolates
for antimicrobial sensitivity (or molecular
typing)
 Inform Microbiology Lab early
 Save specimens and isolates
 Be alert for additional isolates that may be
part of the outbreak

 Identify the following:
 Resources (personnel, supplies, laboratory)
 Lead investigator
 Person responsible for statistical analysis of
the data

VII. STEPS IN CONDUCTING AN OUTBREAK
INVESTIGATION
Step 1: Learn about the topic
Step 2: Establish the Existence of an Outbreak
Step 3: Verify the Diagnosis
Step 4: Define and Identify Cases
Step 5: Describe and orient the data in terms of time,
place, and person
Step 6: Develop Hypotheses
Step 7: Evaluate Hypotheses
Step 8: Refine Hypotheses and Draw Conclusions
Step 9: Implement Control and Prevention Measures
Step 10: Communicate Findings

Research about the disease
through
 Infectious Diseases
practitioner
 Clinical Epidemiologist
 Laboratory personnel
 Infection control/ Infectious
Diseases textbooks
 Medical Journals

Step 2: Establish the Existence of an
Outbreak
IS THIS AN OUTBREAK?
More cases than expected in a given place
over a given time.
Determine the expected number of cases
for the area in the given time frame.
Compare the current number of cases with
the number from the previous weeks,
months or years
 Hospital surveillance records
 Hospital discharge records or census
 Morbidity and mortality records

Outbreak
IS THIS A PSEUDO-OUTBREAK?
• Clusters of positive cultures in patients
without evidence of disease (colonization)
• A perceived increase in infections because
surveillance was not previously being
conducted or because surveillance
definitions, intensity or methods have
changed

Outbreak
What could cause an artificial increase (pseudo-
outbreaks)?
 Alterations in surveillance system:
 New personnel
 New definition
 New case finding method
 New procedure in reporting
 Increased awareness
 New Laboratory procedure
 New diagnostic tests, laboratory equipment
 New technician
 New susceptible population
 New ward, increase in size of population

Ensure that the disease has been properly
diagnosed.
Be certain that the increase in diagnosed cases
is not the result of a mistake in the laboratory.
Confirm the diagnosis:
 Clinical syndrome (signs & symptoms)
 Epidemiologic risk (person, place, time)
 Laboratory & diagnostic tests

Establish a case definition
Inclusion criteria:
A. Clinical criteria (symptoms, signs & onset)
B. Epidemiologic criteria (person, place, time)
C. Laboratory criteria (culture results & dates)
Case Classification:
A. Suspect/Possible- fewer of the typical clinical features
B. Probable- has the typical clinical features of the
disease without laboratory confirmation
C. Confirmed- has the typical clinical features of the
disease and laboratory confirmation
Exclusion Criteria (for suspect and probable)

Identify and count cases
 Interview staff, patients
 Review patients records, log books, employee health
records
 Review lab records
 Infection surveillance data
Passive surveillance
 Send out letters describing the situation and ask for
reports
Active surveillance
 Do telephone surveys or visit the facilities to collect
information

Collect Case Data
 Identifying information
 Demographic information
 Clinical information
 Risk factor information
 Underlying diseases
 Invasive procedures
 Surgical risk factors
 Laboratory test results

Complete Line Listing
 A table consisting of important variables such as
identification number, age, sex, signs& symptoms,
lab test results.
 New cases are added to a line listing as they are
identified.
Case
#
Initials Date
of
report
Date
of
onset
Diagnosis Age Sex symptoms P.E. Labs
1 MC 2/13 2/4 HAP 67 M Cough,
fever
crac
kles
CXR,

Step 5: Describe and Orient the Data in Terms
of Time, Place, and Person
Descriptive Epidemiology
 Provide a comprehensive
description of an outbreak
by showing its trend over
time, its geographic extent
(place), and the populations
(people) affected by the
disease.

Time: Epidemic Curve
Epidemic curve
 A graph of the number of cases by their
date of onset
 Gives a simple visual display of the
outbreak’s magnitude and time trend.
 Y axis= # of cases
 X axis= date of onset/time

Epidemic Curve
Cases
Day
s >
probable
period of
exposure
<<Minimum>>
<<incubation>
>
<Duration ofoutbreak>
<<<<<<<<<<Maximumincubation >>>>>>>>>>

Epidemic Curve
Common Source
8
7 14
6 13
2 3 12 12
4 1 5 11 9 10 11
1 2 3 4 5 6 7 8 9 10 days
Continuous Source
7
2 6 8 10 13
1 3 4 5 11 9 12
1 2 3 4 5 6 7 8 9 10 11 12 12 days
Person to Person Spread
day
s

Place: “Spot Map”
Plotting cases on a map
 Leads on nature & source of outbreak
 Provides information on the geographic
extent of a problem
 Useful to track spread by water, air,
person to person, distribution route of
contaminated item
 Indicate occurrence of cases & not rates

Ground floor 2nd floor
Blue Unit (vacant)
Green Unit
Red Unit
Brown Unit
Social Admin
Kitchen
Laundry Clinics
Services
Business
Office
Classes
Technical
3
24
8
6
2
7
45
14
9
113
12 11 10
18
17
16
15
23
22
21
20
19
29
28
27
26
25
33
32
3134
31
30
33
35
36
37
1 2
3
4
8
7 6
5
12
11
10
9
17
16
15
14
13
24
1918
23
22
21
20
27
26
25
28
29
30
31
32
33
35
36
37
38
39
40
41 42

Person
Determine what populations are at risk for the
disease by characterizing by person.
 Age, gender
 Health status:
 Increased susceptibility
 Risk factors
 Underlying disease
 Exposures
 Procedures
 Drug, IV line

 Formulate a hypothesis to explain why and how the
outbreak occurred based on results of preliminary
investigation.
 Hypothesis should address the source of the agent,
the mode of transmission, and the exposures that
caused the disease.
 Clues from clinical syndrome
 Clues from etiologic agent
 Clues from case interviews (have in common?)
 Clues from existing knowledge base

 Comparison of the hypotheses with the
established facts.
 Analytic Epidemiology
 Cohort studies
 Compare groups of people who have been exposed
to suspected risk factors with groups who have not
been exposed.
 Case-control studies
 Compare people with disease (case patients) with a
group of people without the disease (controls)
 Statistical Methods
 Lab and Environmental Studies

Step 8: Refine Hypotheses and Draw
Conclusions
 When an outbreak occurs, you
should consider what questions
remain unanswered about the
disease.
 Draw conclusions from descriptive
or analytic studies
 Causal inferences

Step 9: Implement and Evaluate
Control and Prevention Measures
 Should be implemented early
 Control strategies:
 Reduce contact between susceptibles and
potential infectives
 Reduce probability source is infective
 Reduce infectiousness of infectious source
 By treatment
 Reduce susceptibility of susceptible hosts
 By treatment/prophylaxis or vaccination
 Interrupt transmission
 Physical/Chemical methods
 Environmental/Engineering methods

Prevention at Source of Infection
 Human source:
 Isolation or treatment of the
human source
 Length of time the patient is
infectious after treatment
must be known

Prevention of Transmission
 Contact and indirect contact:
 Prevent contact, wear gloves if contact
is necessary, handwashing
 Airborne or Droplet:
 Wearing mask with sufficient filtering
ability.
 Simple surgical mask sufficient for
large droplet (as long as the mask is
dry)
 Masks with HEPA type filters for droplet
nuclei
 Food and water borne:
 Avoid suspected food and water

Prevention: Protection of At Risk Person
 Protection of susceptible
individuals
 Immunization (passive or
active, if time permits)
 Chemoprophylaxis

1. Communicate preliminary assessments
and recommendations (letter, memo)
 Communicate any changes necessitated by
the outbreak analysis to the appropriate
departments
2. Prepare interim/final report
 Issue a concluding report to the hospital or
healthcare facility committees

VIII. CASE STUDY 1
 An ICC nurse receives a report from the NICU of an
increased number of cases of sepsis 2 to
Burkholderia cepacia bloodstream infection among
newborns who were delivered via normal
spontaneous delivery from October 1-31, 2015.
 For the month of October 2015, 16 out of 59 newborn
babies were treated for sepsis. For the 16 patients,
blood cultures were taken during the first few hours of
life (ranging from 6 hours to 24 hours). All blood
cultures were positive for Burkholderia cepacia.

OUTBREAK INVESTIGATION:
CASE STUDY
Step 1: Learn about
the topic
The ICC nurse looks up Burkholderia
cepacia in her desk copy of Bergy’s
Manual of Systematic Bacteriology
and Infectious Diseases textbook by
Mandell. She found out that
Burkholderia cepacia is a gram
negative bacillus commonly found in
soil and moist environments and
capable of surviving and growing in
nutrient-poor water. It is an important
opportunistic pathogen in
hospitalized and
immunocompromised patients.

CASE STUDY
Step 2: Establish
the existence of an
outbreak
The NICU averages about 2 %
infections per month. The rate of
infection appeared to begin to rise
around May 2015.
September’s BSI rate was 3% and
October’s rate was 27%.
There was no past record of BSI
caused by Burkholderia cepacia.
However, there were past records of
BSI caused by other organisms
(Pseudomonas aeruginosa and
Staphylococcus aureus)

CASE STUDY
Step 3: Verify the
diagnosis
The ICC nurse reviewed the charts
and culture results of the 16 patients
who developed BSI.
She visited 5 of the patients with a
positive culture for B. cepacia who
were still admitted.
She asked the medical and nursing
staff from NICU and DR if there were
any new personnel, new practices,
equipment or solutions used.

CASE STUDY
Step 4: Define and
Identify Cases
The initial case definition is, “Any
newborn baby developing a BSI
following normal spontaneous
delivery performed in the past 6
months. ”
The ICC nurse called the micro lab
and asked for 2 reports:
one screening for Blood cultures from
the NICU and another screening for
any positive Burkholderia cepacia
cultures from the NICU from May 2015
to present.

CASE STUDY
Step 5: Describe
and Orient the Data
in terms of time,
place, and person
All charts were reviewed using a data
collection form developed by the ICC.
Seven additional BSI’s were identified
related to October 2015 deliveries.
Burkholderia cepacia caused five of
the infections.

0.0
5.0
10.0
15.0
20.0
May Jun Jul Aug Sep Oct Nov
Burkholderia
others

Place
 A total of 59 babies were delivered in the
month of October. 35 babies were delivered
via NSD while 24 were via CS. All 16 babies
with BSI were delivered via NSD in Delivery
Room # 3.
 NSDs are performed in DR # 3 and 4.
Cesarean Deliveries are performed in DR # 1
and 2

Person
 Obstetrician X is associated with 9/16 deliveries of
newborns who developed Burkholderia cepacia BSI.
She has been practicing for 10 years in the hospital.
 Nurse A, a DR nurse assisted the deliveries of 16/16
known Burkholderia cepacia BSI cases. Records
showed that she was newly hired and started on
October 1, 2015
 Nurse B, a NICU nurse performed newborn care to
8/16 babies who developed B. cepacia BSI. She has
been employed for 5 years.

CASE STUDY
Step 6: Develop a
Hypothesis
It was decided to narrow down the
case definition to:
A BSI that is culture positive for
Burkholderia cepacia in a newborn
patient who was delivered via NSD in
the month of October 2015.
The tentative hypothesis is that
patients are being exposed to
Burkholderia cepacia in the Delivery
Room or NICU.

CASE STUDY
Step 7: Test the
Hypothesis
The ICC nurse notes that Obstetrician
X was involved in 9/16 cases,
Nurse B was involved in 8/16 cases,
and Nurse A was involved in all 16/16
cases.
She decides to determine if their
presence during these deliveries is
significant.

CASE STUDY
Step 7: Test
Hypotheses
The ICC nurse reviewed perinatal and
intra-operative care by interviewing
obstetricians, OB and Pedia residents, and
other D.R. and NICU personnel and by
observing a NSD procedure performed by
Obstetrician X in D.R. # 3 where both Nurse
A & Nurse B were assisting.
Nurse A prepared the patient in labor
prior to NSD. Aseptic technique was
performed. Cotton cherries pre-soaked in
betadine solution was used for cleaning
the perineal area. The umbilical cord was
clamped using sterile clamps and was cut
by a disposable sterile blade.

CASE STUDY
Step 7: Test
Hypotheses
Nurse B assisted the Pediatrician in
performing newborn care. Aseptic
technique was performed while handling
the baby. Sterile suction tubing was used
for suctioning of airways. The newborn
was bathed using pre-boiled water. Cord
care was done using 70% isopropyl
alcohol.

CASE STUDY
Step 7: Test
Hypotheses
Environmental cultures were done to
determine the source of the outbreak.
A culture of the ff. were done:
 Cotton cherries pre-soaked in
Betadine solution in DR #3
Betadine solution stored in big
bottles at DR #3
 Kelly pads in DR# 3
 Pre-boiled water used for bathing
newborns
Bath tub used during bathing of
newborns

CASE STUDY
Step 7: Test
Hypotheses
Result of cultures:
 Cultures of cotton cherries pre-
soaked in Betadine solution in DR #3
grew Burkholderia cepacia.

CASE STUDY
Step 8: Refine
Hypotheses and
Draw Conclusions
Newborn babies who were delivered
via NSD in October 2015 developed
Bloodstream infection due to
exposure to Burkholderia cepacia in
Delivery Room # 3.
The technique used by Nurse A in
preparing patients in labor by using
cotton cherries pre-soaked in
contaminated Betadine solution for
cleaning the perineal area caused the
exposure of newborn babies to B.
cepacia during delivery.

CASE STUDY
Step 9: Implementing
Control and
Prevention Measures
The ICC nurse recommends a change in
procedure in preparing patients in labor
prior to NSD.
Cherries pre-soaked in betadine
solution used for prep were not allowed
in the DR. Sterile cotton cherries packed
for single use and Betadine solution
stored in small sterile containers were
recommended.
Aseptic technique during delivery and
newborn care was reinforced.
Nurse A was required to attend in-
sevice ICC seminar.

CASE STUDY
Step 10:
Communicate
Findings
All staff was informed of findings
and the procedure change.
A written summary of findings was
distributed to appropriate staff.

STEPS IN CONDUCTING AN OUTBREAK
INVESTIGATION
Step 2: Establish the Existence of an Outbreak
Step 5: Describe and orient the data in terms of time,
place, and person
Step 8: Refine Hypotheses and Draw Conclusions
Step 9: Implement Control and Prevention Measures

VIII. CASE STUDY 2
 On March 2015, the ICU Link Nurse was the charge nurse on
duty. Upon updating the cultures of patients, the link nurse has
noticed that 4 out of 10 patients in the ICU have growth of
Klebsiella Pneumoniae Carbapenemase (+) in their cultures.
 The Link Nurse immediately notified the Infection Prevention
and Control Office. The surveillance coordinator together with
the Link Nurse conducted an on-the-spot audit of Infection
Prevention and Control Practices of all healthcare workers at the
ICU and reviewed the interactions that occurred with the
patients.

CASE STUDY
Step 1: Learn
about the
topic
The link nurse reads about Klebsiella
pneumoniae carbapenemase from
the Infectious Diseases textbook by
Mandell. She found out that Klebsiella
pneumoniae carbapenemase is a gram
negative bacteria which develop
resistance to most antibiotics including
cabapenems. It is a common cause of
nosocomial infections such as UTI,
pneumonia, and meningitis. It is an
important opportunistic pathogen in
hospitalized and immunocompromised
patients.

CASE STUDY
Step 2: Establish
the existence of
an outbreak
The rate of infection due to KPC at
the ICU appeared to begin to rise
around March 2015.
The KPC HAI rates for the past 6
months were reviewed.
There were no HAIs 2 to KPC last
October, November, January and
February 2015.
There was a past record of HAI 2 to
KPC last December (2 cases of
UTI).

CASE STUDY
Step 3: Verify
the
diagnosis
The ICU link nurse reviewed the
charts and culture results of the 4
patients who developed HAI 2 to
KPC.
She correlated the culture results
with the clinical findings of the
patients.
Patient A.N.- VAP 2 to KPC
Patient B.L- VAP 2 to KPC
Patient N.D.- CAUTI 2 to KPC
Patient S.R.- Infected Decubitus
ulcer 2 to KPC

CASE STUDY
Step 4: Define
and Identify
Cases
The initial case definition is, “Any
ICU patient developing a HAI
secondary to KPC in the month of
March 2015. ”
The ICU link nurse called the
micro lab and asked for a report:
A report screening for any
positive culture of Klebsiella
pneumoniae carbapenemase from
the ICU from March 1 to 31, 2015.

CASE STUDY
Step 4: Define
and Identify
Cases
Line List:
Name Isolate Source Room # Date
collected
Date
admitted
at ICU
Date
transferred
to floor
A.N. (+) KPC ETA ICU 2 3/12/15 3/10/15 3/15/15
B.L. (+) KPC ETA ICU 2 3/8/15 3/4/15 3/10/15
N.D. (+) KPC Urine ICU 5 3/5/15 3/2/15 3/15/15
S.R. (+) KPC Wound ICU 9 3/8/15 3/5/15 3/11/15

CASE STUDY
Step 5: Describe
and Orient the
Data in terms of
time, place, and
person
All ICU charts were reviewed using
a data collection form developed by
the IPCO.

0.0
5.0
OCT NOV DEC JAN FEB MAR
KPC
others

Place
 ICU 2 = 2 CASES (Patients B.L. & A.N.)
 ICU 5 = 1 CASE (Patient N.D.)
 ICU 9 = 1 CASE (Patient S.R.)

Person
RISK FACTORS FOR KPC HAI:
 Patient A.N. was intubated since 3/08/2015. He is under the
care of Dr. B. He was cared by Nurse Love on 3/8/2015.
 Patient B.L. was intubated since 3/4/2015. He is under the care
of Dr. A. He was cared by Nurse Competence on 3/8/2015.
 Patient N.D. has a foley catheter since 3/4/2015. He is under the
care of Dr. A. He was cared by Nurse Compassion on 3/5/2015.
 Patient S.R. has a 2 x 2 bedsore observed since 3/5/2015. He is
under the care of Dr. C. He was cared by Nurse Competence on
3/8/2015. He was also handled by Nurse Compassion on
3/5/2015.

CASE STUDY
Step 6: Develop a
Hypothesis
The tentative hypothesis is that
Klebsiella pneumoniae
carbapenemase infection is being
transmitted from an index case to
other patients in the ICU probably
because of a break in infection
control practices.

CASE STUDY
Step 7: Test the
Hypothesis
The ICU link nurse notes that Nurse
Compassion was involved in 2/4 cases and in
the first case of KPC (patient N.D.)
Nurse Competence was involved in 2/4 cases,
and Nurse Love was involved in 1/4 cases.
Dr. A was involved in 2/4 cases (B.L. and
N.D.)
She decides to determine if their presence
are significant by conducting an audit of their
practices.

CASE STUDY
Step 7: Test
Hypotheses
Audit of Healthcare Worker Practices:
Nurse Competence has a hand hygiene
compliance of 15%.
Nurse Compassion has a hand hygiene
compliance of 50%, but he uses the same gloves
for draining the urinary bag.
Dr. B and A both have a hand hygiene compliance
of 30%.
On 3/10/2015, Patient A.N. was immediately
admitted to the ICU-2 post-OR due to severe
hemodynamic instability. The room has just been
vacated by Patient B.L.

CASE STUDY
Step 7: Test
Hypotheses
Environmental cultures at the
ICU were done to determine the
source of the outbreak.
A culture of the ff. were done:
 Bedrails at ICU Beds 2,5,9
 Gloves used by Nurse
Compassion for draining urine of
patient N.D.

CASE STUDY
Step 7: Test
Hypotheses
Result of cultures:
 Bedrails at ICU Beds 2 & 5 were
positive for KPC
 Gloves used by Nurse
Compassion for draining urine of
patient N.D. was positive for KPC

CASE STUDY
Step 8: Refine
Hypotheses and
Draw Conclusions
Patient N.D. with CAUTI 2 to KPC is the
index case (infected March 5, 2015).
Nurse Compassion transmitted KPC from
the urine of Patient N.D. to the wound of
Patient S.R. on March 5, 2015 because she
does not change gloves when draining the
urine bag.
Patient B.L developed VAP 2 to KPC on
March 8, 2015 which was transmitted from
Patient S.R. through the contaminated
hands of Nurse Competence (HHC of
15%).

CASE STUDY
Step 8: Refine
Hypotheses and
Draw Conclusions
The wound of Patient S.R. was infected
with KPC on March 8, 2015 which was
transmitted from patient B.L. through the
contaminated hands of Nurse Competence
(15% Hand hygiene compliance).
 Patient A.N. developed VAP 2 to KPC on
March 12, 2015 because of inadequate
environmental cleaning of ICU 2 which was
just vacated by Patient B.L. with VAP 2 to
KPC.

CASE STUDY
Step 9:
Implementing
Control and
Prevention
Measures
The ICU link nurse recommends the
following:
 Implement contact precautions for all
patients with KPC HAI and Droplet
Precautions for all patients with VAP 2
to KPC.
 Gloves used for draining urine should
be disposed immediately after single
use.
 Routine environmental cleaning of all
ICU cubicles should be done.
 Nurse Competence and Nurse
Compassion were required to attend
in-service Infection Control seminar.

CASE STUDY
Step 10:
Communicate
Findings
All staff was informed of findings
and the recommendations.
A written summary of findings
was distributed to appropriate staff.

References:
 http://www.cdc.national center for chronic disease
prevention and health promotion. Outbreak
Investigation
 http://www.idready.org. Aragon, T., W. Enanoria, A
Reingold. Conducting an outbreak investigation in 7
steps. Center for Infectious Disease Preparedness,
UC Berkeley School of Public Health.
 Outbreak investigation-Case Study by University of
Michigan Hospitals and Health Centers, Infection
Control & Epidemiology 2002.

Outbreak Investigation

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Outbreak Investigation