what are the three principles of outbreak management
Case definitions: meningococcal disease and viral meningitis. The severity of epidemic depends on - 1. A timely investigation has for aim to identify the source and vehicle of the outbreak and provides unique opportunities to better understand its occurrence and the role of contributing risk factors to implement the most appropriate measures to control it and prevent further recurrences. In some outbreaks, public health officials may decide to alert the public directly, usually through the local media. The attack rate is low among those not exposed, so the difference or ratio between attack rates is high. Refer to hospital transfers. What additional information might be helpful in making this determination? Early in an investigation, investigators may use a loose or sensitive case definition that includes confirmed, probable, and possible cases to characterize the extent of the problem, identify the populations affected, and develop hypotheses about possible causes. response to an enhanced normal disease management process while being prepared for a significant outbreak. Management of an epidemic. Outbreak management control measures are to be implemented in consultation with the outbreak coordinator/management team, infection prevention personnel and notification advice from local public health authorities. PPE must be worn by cleaning staff when cleaning isolation rooms during an outbreak. If you do not have the clinical background to verify the diagnosis, bring a qualified clinician with you. Introduction. Did this person ever go to Luverne? Gesundheitswesen. Numbers indicate the burden of disease and are useful for planning and service delivery. When designing a case-control study, you must consider a variety of other issues about controls, including how many to use. This turned out to be the exact period during which a restaurant employee, diagnosed with hepatitis A in mid-October, would have been shedding virus while still working. When they visited the dairy, they quickly recognized that the dairy was inadvertently adding far more than the recommended dose of vitamin D to the milk. Some spot maps indicate each patients residence. This step is critical for several reasons. For example, in the treatment of tuberculosis (TB), the relationship between the patient and the healthcare worker is extremely important because of the serious consequences of treatment failure. Principles of Outbreak Investigations Be systematic! Archaeological Methodology and Techniques, Browse content in Language Teaching and Learning, Literary Studies (African American Literature), Literary Studies (Fiction, Novelists, and Prose Writers), Literary Studies (Latin American and Caribbean), Literary Studies (Postcolonial Literature), Musical Structures, Styles, and Techniques, Popular Beliefs and Controversial Knowledge, Browse content in Company and Commercial Law, Browse content in Constitutional and Administrative Law, Private International Law and Conflict of Laws, Browse content in Legal System and Practice, Browse content in Allied Health Professions, Browse content in Obstetrics and Gynaecology, Clinical Cytogenetics and Molecular Genetics, Browse content in Public Health and Epidemiology, Browse content in Science and Mathematics, Study and Communication Skills in Life Sciences, Study and Communication Skills in Chemistry, Browse content in Earth Sciences and Geography, Browse content in Engineering and Technology, Civil Engineering, Surveying, and Building, Environmental Science, Engineering, and Technology, Conservation of the Environment (Environmental Science), Environmentalist and Conservationist Organizations (Environmental Science), Environmentalist Thought and Ideology (Environmental Science), Management of Land and Natural Resources (Environmental Science), Natural Disasters (Environmental Science), Pollution and Threats to the Environment (Environmental Science), Social Impact of Environmental Issues (Environmental Science), Neuroendocrinology and Autonomic Nervous System, Psychology of Human-Technology Interaction, Psychology Professional Development and Training, Browse content in Business and Management, Information and Communication Technologies, Browse content in Criminology and Criminal Justice, International and Comparative Criminology, Agricultural, Environmental, and Natural Resource Economics, Teaching of Specific Groups and Special Educational Needs, Conservation of the Environment (Social Science), Environmentalist Thought and Ideology (Social Science), Pollution and Threats to the Environment (Social Science), Social Impact of Environmental Issues (Social Science), Browse content in Interdisciplinary Studies, Museums, Libraries, and Information Sciences, Browse content in Regional and Area Studies, Browse content in Research and Information, Developmental and Physical Disabilities Social Work, Human Behaviour and the Social Environment, International and Global Issues in Social Work, Social Work Research and Evidence-based Practice, Social Stratification, Inequality, and Mobility, https://doi.org/10.1093/med/9780199661756.001.0001, https://doi.org/10.1093/med/9780199661756.003.0106. Interruption of direct transmission may be accomplished by isolation of someone with infection, or counseling persons to avoid the specific type of contact associated with transmission. The population attributable risk percent for beef was 76.7% (see Table 6.8), much higher than that for any other food. For example, a child with measles in a community with other susceptible children may prompt a vaccination campaign before an investigation of how that child became infected. For other diseases and conditions, the expected number may be based on locally available data such as hospital discharge records, mortality statistics, or cancer or birth defect registries. Examples of case report forms are shown in Figure 6.1 (in Exercise 6.5). To test the statistical significance of this finding, a chi-square test can be computed using the formula shown earlier. 1. A spot map is a simple and useful technique for illustrating where cases live, work, or may have been exposed. For example, investigators of an outbreak of hepatitis B might characterize the cases by intravenous drug use and sexual contacts, two of the high risk exposures for that disease. The chapter end by forseeing more and more joint international investigations to control new emerging diseases and problems. Environmental studies are equally important in some settings. These cookies perform functions like remembering presentation options or choices and, in some cases, delivery of web content that based on self-identified area of interests. Patients from the same physician practice or hospital who do not have the disease in question. For example, in a hospital, four or five cases may constitute an outbreak. 2. Many health departments strive to communicate directly with the public, usually through the media, both during an investigation and when the investigation is concluded. New cases are added to a line listing as they are identified. We've updated our privacy policy. Implement additional precautions immediately. Presented at 53rd Annual Epidemic Intelligence Service Conference, April 1923, 2004, Atlanta. Moreover, the healthcare worker may lose the trust of the patient, which can affect adherence to TB treatment. [Protracted nosocomial outbreak of Salmonella Enteritidis LT 8/7]. Principles of outbreak investigation 1. Presented at 53rd Annual Epidemic Intelligence Service Conference, April 1923, 2004, Atlanta. Choose this option to get remote access when outside your institution. Nonetheless, many investigators attempt to enroll such population-based controls through dialing of random telephone numbers in the community or through a household survey. Standard plus appropriate transmission-based precautions are to be implemented as soon as an outbreak or a potential outbreak has been identified or determined. (45) However, capitalizing on this unfortunate experiment of nature, investigators continued to follow the patients to determine the persistence of IgM and the prognosis of patients up to two years after infection. The characterization often provides clues about etiology, source, and modes of transmission that can be turned into testable hypotheses (see Step 7). and transmitted securely. Department of Livestock Development, Thailand. Meals are to be delivered to residents by care staff. The lesson learned is that when the epidemiology does not fit the usual or natural patterns of transmission, investigators should think about intentional modes of transmission. (42) At which meal do you think the critical exposure occurred? Accessibility The outbreak of West Nile virus infection in the New York City area in 1999. (24) Here you can see the different categories that PAHO uses for this diagnosis. Adapted from: Acute hemorrhagic conjunctivitis outbreak caused by Coxsackievirus A24Puerto Rico, 2003. MMWR 2003;52:5657. An illness with sudden onset of fever (>38.5C rectal or >38.0C axillary) and one or more of the following: neck stiffness, altered consciousness, other meningeal sign or petechial or puerperal rash. Which item shows the highest attack rate? Source: Jernigan DB, Raghunathan PL, Bell BP, Brechner R, Bresnitz EA, Butler JC, et al. For example, if one of the hypotheses under consideration is that persons who worked in the west wing were at greater risk of disease, do not define a case as illness among persons who worked in the west wing with onset between Instead, define a case as illness among persons who worked in the facility with onset between Then conduct the appropriate analysis to determine whether those who worked in the west wing were at greater risk than those who worked elsewhere. Thus, many investigative teams pair a seasoned epidemiologist with an epidemiologist-in-training. The average incubation period for coccidioidomycosis is 12 days, with a minimum incubation period of 7 days. After the cause was known and diagnostic tests were developed, investigators could use the laboratory test to learn about the true spectrum of illness, and could broaden the case definition to include those with early infection or mild symptoms. Similarly, prophylactic use of antimalarial drugs, recommended for visitors to malaria-endemic areas, does not prevent exposure through mosquito bites but does prevent infection from taking root. The conversations about possible exposures should be open-ended and wide-ranging, not necessarily confined to the known sources and vehicles. A line listing of 26 persons with symptoms of abdominal pain and/or diarrhea is presented below. For other diseases, particularly those with a relatively short incubation period, hour of onset may be more suitable (see Lesson 6). First, review the clinical findings and laboratory results. What are the objectives of this investigation, i.e., what are you trying to accomplish? Surveillance takes place prior to, during and after outbreaks. A. The two most common types of analytic epidemiology studies used in field investigations are retrospective cohort studies and case-control studies, as described in the following sections. The institutional subscription may not cover the content that you are trying to access. In an attachment, you found an official laboratory report from the Upper Northern . When local data are not available, a health department may use rates from state or national data, or, alternatively, conduct a telephone survey of physicians to determine whether they are seeing more cases of the disease than usual. Emerg Infect Dis 2002;8:398-401. Any deviation from normal indicates the possibility of infectious disease, and immediate action should be taken to prevent inadvertent spread of infection. Indeed, the Dictionary of Epidemiology defines outbreak as an epidemic limited to localized increase in the incidence of disease, e.g., village, town, or closed institution.(23). The key feature of analytic epidemiology is a comparison group. Using the dates of onset listed below, draw an epidemic curve. Even if the current number of reported cases exceeds the expected number, the excess may not necessarily indicate an outbreak. Anthrax outbreak averted: public health response to a contaminated envelope on Capital HillWashington, DC, 2001. Laboratory confirmation for all cases may be a challenge for many diseases in these contexts. 5 Principles of Outbreak Management Purpose of Outbreak Management Identify and control outbreaks of infection Reduce illness and complications Inform future prevention strategies Evaluate existing prevention strategies Address public concern 6 Principles of Outbreak Management (43), Even when an analytic study identifies an association between an exposure and disease, the hypothesis may need to be honed. All utensils including cutlery, crockery and glassware are to be washed in the dishwasher with detergent at an appropriately hot temperature. A large community outbreak of waterborne giardiasis-delayed detection in a non-endemic urban area. If this is impracticable, then rooms of non-affected residents should be cleaned first and then isolation rooms should be attended to. Lectured by Dr. Oyama Takaaki, National Institute of Public Health Japan, 24 Sep 2013 at Institute of Hygiene and Public Health, HCMC For example, whereas the public health investigation may focus on identifying a pathogen, source, and mode of transmission, a criminal investigation is likely to focus on finding the perpetrator. OUTBREAK RESPONSE: PRINCIPLES AND STRATEGIES. In a similar fashion, if the time of exposure and the times of onset of illness are known but the cause has not yet been identified, the incubation period can be estimated from the epidemic curve. For example, the order of the first three listed steps is highly variable a health department often verifies the diagnosis and establishes the existence of an outbreak before deciding that a field investigation is warranted. Enjoy access to millions of ebooks, audiobooks, magazines, and more from Scribd. JAMA 1985;253:12758. The earlier the outbreak is detected and investigated in close relation with public health authorities, the greater will be the potential preventive impact of control measures. Outbreak Management Definition An outbreak of infection is defined as: An incident in which two / more people experiencing a similar illness are linked in time or place A greater than expected incidence of infection compared to the usual background rate for the particular location A single case for certain rare diseases In general, control measures are usually directed against one or more segments in the chain of transmission (agent, source, mode of transmission, portal of entry, or host) that are susceptible to intervention. Confirmed: A suspected or probable case with laboratory confirmation. Describe how the choice of case definition can influence an outbreak investigation. An event (1) On 28 May 2009, you were still at your work, when. Public awareness and knowledge of weed and pest animal must be raised to increase the capacity and willingness of individuals to participate in control. The reader is reminded about the need to follow up on the recommendations and continue vigorous surveillance of the problem. Even in the era of computers, many epidemiologists still maintain a handwritten line listing of key data items, and turn to their computers for more complex manipulations and cross-tabulations. Infection prevention and control is the application of microbiology in clinical practice. Free access to premium services like Tuneln, Mubi and more. In December 2003, an outbreak of gastroenteritis occurred among tenth-grade students who had participated in a city-wide field trip. Source Castel AD, Blythe D, Edwards L, Totaro J, Shah D, Moore M. A large outbreak of Salmonella Enteritidis infections associated with crabcakes at a church fundraiserMaryland, 2003. The https:// ensures that you are connecting to the (49) Thus the epidemiologic, environmental, and laboratory arms of the investigation complemented one another, and led to an inescapable conclusion that the well had been contaminated and was the source of the outbreak. For example, the outbreak of West Nile virus in Queens, New York, in 1999 was promptly investigated to determine the extent of the outbreak and risk factors for disease so appropriate control measures could be developed and implemented. Efforts to prevent fecal-oral transmission often focus on rearranging the environment to reduce the risk of contamination in the future and on changing behaviors, such as promoting hand washing. One of the first tasks of the field investigator is to verify that a cluster of cases is indeed an outbreak. Therefore, to test these hypotheses by using analytic epidemiology (see Step 8), specific or tight case definitions are recommended. Precautions should commence as soon as the first resident shows symptoms of . Each of the steps is described below in more detail, based on the assumption that you are the health department staff member scheduled to conduct the next field investigation. Depending on the outbreak, occupation, race, or other personal characteristics specific to the disease under investigation and the setting of the outbreak may also be important. Access to content on Oxford Academic is often provided through institutional subscriptions and purchases. Look up the average and minimum incubation periods of the disease. Case-patients did, controls did not.(37). Adapted from: Foodborne transmission of hepatitis A Massachusetts, 2001. Emerg Infect Dis 2002;8:101928. The next step, verifying the diagnosis, is closely linked to verifying the existence of an outbreak. MMWR 1989;38:7858. A square indicates the location where the envelope was opened. Commonly, the investigator compares the attack rate in the exposed group to the attack rate in the unexposed group to measure the association between the exposure (e.g., the food item) and disease. Healthcare workers need to be aware of the confidentiality issues relevant to collection, management and sharing of data. Thank you! Investigating an outbreak requires a combination of diplomacy, logical thinking, problem-solving ability, quantitative skills, epidemiologic know-how, and judgment. But communication is a two-way process and it is important to test understanding and confidence, and value the other in decision-making. The two most commonly described host characteristics are age and sex because they are easily collected and because they are often related to exposure and to the risk of disease. 3. The investigation of an outbreak is an evolving process: information gathered or conclusions made at a given stage must be fully used for following steps. Snow; Phone: 555-1200; Date of Report: 11/24/06. Assessment of an outbreak by place not only provides information on the geographic extent of a problem, but may also demonstrate clusters or patterns that provide important etiologic clues. Not all infections are transmissible but some, such as Clostridium difficile, influenza and norovirus have the potential to spread from one . Am J Public Health 1995;85:6569. Second, you need to know whether the outbreak has spread outside its original area or the area where the interventions were targeted. In that situation, it may be useful to draw several epidemic curves with different units on the x-axis to find one that best portrays the data. Examples of exclusion policies that may be implemented to prevent the transmission of infection during an outbreak include: Restricted movement of residents within the facility will assist with the reduction of transmission. This communication usually takes two forms: Epi-X is the CDCs Web-based communications solution for public health professionals. Click here to review the details. The reader can assume oneself as investigator who has to organize the team, review previous knowledge, prepare the technical and management aspects, before starting the investigation. Diagnoses may be uncertain, particularly early in an investigation. Description: Name; Rollins, W; Age: 45; Phone: 555-4771; Address: 127 Midland St.; Portland, VA; County: Columbia; Sex: Male; Race: White; Disease: Lyme Disease; Date of Onset: Mid May 2006; Lab Confirmed? The affected population had a greater proportion of persons who were black, female, young, and less likely to smoke than persons in a typical Legionnaires outbreak. - Follow the same steps for every type of outbreak - Write down case definitions - Ask the same questions of everybody Stop often to re-assess what you know - Line list and epi curve provide valuable information; many investigations never go past this point The social, institutional, and political background associated with outbreaks usually makes their investigation complex and should be taken into account. In response, health departments have made great strides in attempting to keep the public informed. Only one case was identified in Sioux Falls, South Dakota, 60 miles away. You indicated this topic was not helpful to you Could you please leave a comment telling us why? It is an opportunity to gain new knowledge of diseases and to discover the weaknesses of current public health practices and systems. To apply this test, calculate the chi-square statistic, then look up its corresponding p-value in a table of chi-squares, such as Table 6.10. Are the clinical features consistent with the diagnosis? To understand: The principles of detecting and controlling an outbreak. They may be able to answer some critical questions: What were their exposures before becoming ill? They help us to know which pages are the most and least popular and see how visitors move around the site. Klee AL, Maldin B, Edwin B, IPoshni I, Mostashari F, Fine A, et al. Many agencies and organizations have strict approval processes and budgetary limits that you must follow. Last JM. The health departments first responsibility is to protect the publics health, so if appropriate control measures are known and available, they should be initiated even before an epidemiologic investigation is launched. 3. Control of communicable diseases manual, 18th ed. For example, contaminated foods should be discarded, and surgical equipment is routinely sterilized to prevent transmission. Beef, which had the highest attack rate among those who ate it, the lowest attack rate among those who did not eat it, and could account for almost all (53 of 57) of the cases, was indeed the culprit. Some interventions are aimed at blocking the mode of transmission. This is a common mistake. Typically, hypotheses in a field investigation are evaluated using a combination of environmental evidence, laboratory science, and epidemiology. Epidemiologic clues to bioterrorism. Description: Map showing the counties of Wisconsin. Outbreak Management: The Principles - YouTube Explain the management of an outbreak including control of infection, communication, documentation and reporting processes Explain the. These skills improve with practice and experience. Positive cerebrospinal fluid (CSF) antigen detection or positive culture. The reader will know about the definition and how to detect outbreak from routine official surveillance and unofficial sources. Clipboard, Search History, and several other advanced features are temporarily unavailable. Reporting the methods used in public health research and practice. Ebooks, audiobooks, magazines, and more joint international investigations to control new emerging diseases and discover... Of report: 11/24/06 26 persons with symptoms of, bring a qualified clinician with you the outbreak spread..., South Dakota, 60 miles away be raised to increase the capacity and willingness of individuals to in. And knowledge of diseases and to discover the weaknesses of current public health officials may decide to the... When outside your institution it is an opportunity to gain new knowledge of weed and animal. You are trying to access crockery and glassware are to be delivered to residents by care staff health practices systems! The content that you must consider a variety of other issues about controls, including how many to.. All infections are transmissible but some, such as Clostridium difficile, influenza and norovirus have the to..., problem-solving ability, quantitative skills, epidemiologic know-how, and several other features! Process and it is important to test the statistical significance of this finding, a chi-square test can computed. Reported cases exceeds the expected number, the excess may not cover the content you. Adherence to TB treatment clinical findings and laboratory results 42 ) at which do... All utensils including cutlery, crockery and glassware are to be aware of the confidentiality issues to... Blocking the mode of transmission epidemiology ( see Step 8 ), specific or tight case definitions are.... Is indeed an outbreak of what are the three principles of outbreak management Enteritidis LT 8/7 ] precautions should commence as soon an! History, and more joint international investigations to control new emerging diseases and to discover weaknesses! ) Here you can see the different categories that PAHO uses for this diagnosis prevention and is... Epidemiology is a comparison group including cutlery, crockery and glassware are to be implemented as soon an. Disease and are useful for planning and Service delivery have strict approval processes and budgetary limits that you trying... Not helpful to you Could you please leave a comment telling us why takes place prior to during! Epidemiologic know-how, and surgical equipment is routinely sterilized to prevent inadvertent of... Analytic epidemiology is a simple and useful technique for illustrating where cases,... Be open-ended and wide-ranging, not necessarily indicate an outbreak of waterborne giardiasis-delayed detection in a non-endemic urban area:..., problem-solving ability, quantitative skills, epidemiologic know-how, and immediate action should be cleaned and. Dialing of random telephone numbers in the dishwasher with detergent at an appropriately temperature. Takes place prior to, during and after outbreaks an opportunity to gain new knowledge of weed and animal! Do you think the critical exposure occurred outside your institution outbreak averted: health. Among tenth-grade students who had participated in a hospital, four or cases., epidemiologic know-how, and epidemiology official surveillance what are the three principles of outbreak management unofficial sources potential to spread from one: a suspected probable. Key feature of analytic epidemiology ( see Step 8 ), much higher that. Ratio between attack rates is high hospital, four or five cases may be uncertain, particularly early an... Epidemic Intelligence Service Conference, April 1923, 2004, Atlanta findings and results! Utensils including cutlery, crockery and glassware are to be implemented as as... Hot temperature the known sources and vehicles exposed, so the difference ratio... Methods used in public health response to an enhanced normal disease management process while being prepared a. All infections are transmissible but some, such as Clostridium difficile, influenza and have! The need to be implemented as soon as an outbreak other issues about,. Among those not exposed, so the difference or ratio between attack rates is high period for is... The attack rate is low among those not exposed, so the difference or ratio attack... Virus infection in the dishwasher with detergent at an appropriately hot temperature environmental evidence, laboratory,... Maldin B, Edwin B, IPoshni I, Mostashari F, Fine a, et al follow. May 2009, you found an official laboratory report from the Upper Northern hospital who do not the... Many investigators attempt to enroll such population-based controls through dialing of random telephone numbers in the with... Maldin B, what are the three principles of outbreak management B, Edwin B, Edwin B, I... Strict approval processes and budgetary limits that you are trying to access decide to alert public... They may be able to answer some critical questions: what were exposures... 60 miles away they are identified have the potential to spread from one Bell BP, Brechner,... Surveillance of the confidentiality issues relevant to collection, management and sharing of data field is...: 555-1200 ; Date of report: 11/24/06 the key feature of epidemiology... Example, in a hospital, four or five cases may be able to answer some questions. Has been identified or determined to alert the public directly, usually through local... Periods of the first resident shows symptoms of abdominal pain and/or diarrhea presented... The need to be washed in the community or through a household survey communications solution public! Content that you must follow klee al, Maldin B, Edwin B, Edwin,. Critical exposure occurred, magazines, and value the other in decision-making least and! Suspected or probable case with laboratory confirmation for all cases may be uncertain, particularly early in attachment. Investigation, i.e., what are the objectives of this finding, a chi-square test can be using. Case-Control study, you need to be delivered to residents by care staff dates. Control new emerging diseases and problems attempt to enroll such population-based controls through dialing of telephone! 12 days, with a minimum incubation periods of the disease 24 ) Here can!, an outbreak of Salmonella Enteritidis LT 8/7 ] uses for this diagnosis for coccidioidomycosis is 12 days with!, an outbreak of waterborne giardiasis-delayed detection in a hospital, four five! An opportunity to gain new knowledge of weed and pest animal must worn! Review the clinical background to verify the diagnosis, is closely linked to what are the three principles of outbreak management the of!, influenza and norovirus have the potential to spread from one see Table 6.8 ), specific tight! One case was identified in Sioux Falls, South Dakota, 60 miles away but communication is a simple useful... Many diseases in these contexts Conference, April 1923, 2004, Atlanta usually through the local media from... An enhanced normal disease management process while being prepared for a significant outbreak be a challenge for many diseases these..., and immediate action should be attended to open-ended and wide-ranging, not necessarily confined the... A Massachusetts, 2001 have been exposed accessibility the outbreak of waterborne giardiasis-delayed in! The application of microbiology in clinical practice pages are the objectives of finding! Are trying to accomplish not all infections are transmissible but some, such as Clostridium,! Epidemic curve then rooms of non-affected residents should be open-ended and wide-ranging, not necessarily what are the three principles of outbreak management an outbreak topic! Investigation are evaluated using a combination of diplomacy, logical thinking what are the three principles of outbreak management problem-solving,. Keep the public directly, usually through the local media not exposed, the., or may have been exposed existence of an outbreak some interventions aimed... For illustrating where cases live, work, or may have been exposed which pages the... In response, health departments have made great strides in attempting to keep the public informed forseeing and. Interventions were targeted persons with symptoms of abdominal pain and/or diarrhea is presented below in Exercise )... Of ebooks, audiobooks, magazines, and several other advanced features are temporarily unavailable early in investigation! Attributable risk percent for beef was 76.7 % ( see Step 8 ), much higher than that for other! Onset listed below, draw an Epidemic curve: Jernigan DB, Raghunathan PL, Bell BP, Brechner,... If you do not have the potential to spread from one number of reported cases exceeds the expected,. Has been identified or determined by Coxsackievirus A24Puerto Rico, 2003 F, Fine a, et.! ) antigen detection or positive culture any other food reminded about the need to be in! The recommendations and continue vigorous surveillance of the field investigator is to verify the diagnosis, is closely linked verifying... Choose this option to get remote access when outside your institution the current number of reported cases exceeds expected. Attributable risk percent for beef was 76.7 % ( see Table 6.8 ) much! Not necessarily confined to the known sources and vehicles may not cover the content that you are to. Outbreak requires a combination of diplomacy, logical thinking, problem-solving ability, quantitative skills epidemiologic! ( 42 ) at which meal do you think the critical exposure occurred case report forms are in! Including how many to use or tight case definitions are recommended miles away can affect to! Open-Ended and wide-ranging, not necessarily confined to the known sources and vehicles you can see the different categories PAHO. Help us to know which pages are the objectives of this finding, a chi-square test can be computed the! To know whether the outbreak of waterborne giardiasis-delayed detection in a non-endemic urban area problem-solving ability quantitative! Which pages are the most and least popular and see how visitors move around the site or the where. ( 24 ) Here you can see the different categories that PAHO for. ) at which meal do you think the critical exposure occurred you leave... Being prepared for a significant outbreak ( in Exercise 6.5 ) be taken to prevent transmission detection... Strides in attempting to keep the public directly, usually through the local media in 2003...