Infectious disease outbreaks in Denmark
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1 Infectious disease outbreaks in Denmark Infectious Disease Epidemiology Course University of Copenhagen October 25, 2017 Luise Müller, Department of Infectious Disease Epidemiology, Statens Serum Institut
2 TODAY What is an outbreak? Why investigate outbreaks? Who is doing what in the investigation of foodborne outbreaks in Denmark? Methodological steps in an outbreak investigation - Descriptive epidemiology - Analytical epidemiology Exercise: Playing the role of the epidemiologist
3 WHAT IS AN OUTBREAK? Occurrence of more cases of a disease than expected - In a specific area - In a specific population - Within a specific time period
4 WHAT IS AN OUTBREAK? Occurrence of more cases of a disease than expected - In a specific area - In a specific population - Within a specific time period Outbreak=epidemic Pandemic: an epidemic occurring worldwide, or over a very wide area, crossing international boundaries and usually affecting a large number of people* *Last J. A dictionary of epidemiology (4th Edition) Oxford University Press 2001
5 WHY INVESTIGATE OUTBREAKS? Stop the outbreak Understand what happened and why Prevent future outbreaks Improve our knowledge Improve surveillance and outbreak detection Training It is fun!
6 WHAT CAUSES FOODBORNE OUTBREAKS IN DENMARK? 49 reported food-borne outbreaks in 2016
7 INVESTIGATION OF FOODBORNE OUTBREAKS IN DENMARK Local outbreaks - E.g. restaurant, private party, drinking water National outbreaks - Cases in two regions or more - International aspect Responsible institutions - Regional food offices - Medical officer - Local laboratories Responsible institutions - Statens Serum Institut Reference laboratory Department of infectious disease epidemiology - Veterinary and food administration - Food Institute at DTU
8 INVESTIGATION OF FOODBORNE OUTBREAKS IN DENMARK Local outbreaks - E.g. restaurant, private party, drinking water National outbreaks - Cases in two regions or more - International aspect Responsible institutions - Regional food offices - Medical officer - Local laboratories The Central Outbreak Management Group Responsible institutions - Statens Serum Institut Reference laboratory Department of infectious disease epidemiology - Veterinary and food administration - Food Institute at DTU
9 STEPS IN AN OUTBREAK INVESTIGATION 1. Confirm outbreak 2. Confirm diagnosis 3. Make a case definition 4. Identify cases and obtain information 5. Describe data: time, place, person 6. Develop hypothesis 7. Test hypothesis: Analytical studies 8. Implement control measures 9. Communicate results
10 DANISH SALMONELLA O:4,5,12; H:I:- OUTBREAK CAUSED BY PORK MEAT LOAF DECEMBER 2016 TO APRIL 2017
11 THE FIRST ALARM January 20, 2017: Laboratory notices an increase of Salmonella O:4,5,12; H:i:- with the same MLVA type February 1, 2017: Danish Patient Safety Authority contacts SSI about a possible Salmonella outbreak in a day care centre in Jutland
12 STEPS IN AN OUTBREAK INVESTIGATION 1. Confirm outbreak 2. Confirm diagnosis 3. Make a case definition 4. Identify cases and obtain information 5. Describe data: time, place, person 6. Develop hypothesis 7. Test hypothesis: Analytical studies 8. Implement control measures 9. Communicate results
13 CASE DEFINITION S. O:4,5,12; H:I:- OUTBREAK Laboratory-confirmed Salmonella O:4,5,12; H:i:- that cluster by WGS and no travel from December 2016 to April Who? - Where? - When?
14 STEPS IN AN OUTBREAK INVESTIGATION 1. Confirm outbreak 2. Confirm diagnosis 3. Make a case definition 4. Identify cases and obtain information 5. Describe data: time, place, person 6. Develop hypothesis 7. Test hypothesis: Analytical studies 8. Implement control measures 9. Communicate results
15 STEPS IN AN OUTBREAK INVESTIGATION 1. Confirm outbreak 2. Confirm diagnosis 3. Make a case definition 4. Identify cases and obtain information 5. Describe data: time, place, person 6. Develop hypothesis 7. Test hypothesis: Analytical studies 8. Implement control measures 9. Communicate results
16 WEEK OF SAMPLE FOR PATIENTS N=21
17 PLACE OF RESIDENCE FOR PATIENTS N=21
18 AGE AND SEX DISTRIBUTION N=21
19 STEPS IN AN OUTBREAK INVESTIGATION 1. Confirm outbreak 2. Confirm diagnosis 3. Make a case definition 4. Identify cases and obtain information 5. Describe data: time, place, person 6. Develop hypothesis 7. Test hypothesis: Analytical studies 8. Implement control measures 9. Communicate results
20 HYPOTHESIS GENERATING INTERVIEWS 17 interviews conducted No common events (apart from the day care) Living alone Simple food habits February 28 - Frozen ready-made meal: pork meat loaf mentioned by two Follow-up interviews on ready-made meals
21 STEPS IN AN OUTBREAK INVESTIGATION 1. Confirm outbreak 2. Confirm diagnosis 3. Make a case definition 4. Identify cases and obtain information 5. Describe data: time, place, person 6. Develop hypothesis 7. Test hypothesis: Analytical studies 8. Implement control measures 9. Communicate results
22 ANALYTICAL EPIDEMIOLOGY Cohort investigations - Used in closed settings e.g. restaurant - Point source outbreaks - Measure of association: relative risk (RR) Case control investigations - No defined group or the group is too big e.g. the Danish population - First you define the ill and then you find some (non-ill) control persons to compare with - Measure of association: odds ratio (OR)
23 CASE CONTROL STUDIE When the cohort is too big!! Aim: to compare exposures (food items consumed) between ill persons and healthy controls Controls - Not ill - From the same population - Should have the same risk of getting the disease How do you select controls? - Friends/family - Neighbour - Hospital records - Danish Civil Registration System (CPR)
24 SALMONELLA OUTBREAK: CASE-CONTROL STUDY - 12 cases Not re-interviewed Exclusion: dead, refused to participate, suspected secondary transmission - 36 controls Matched by age, sex and municipality
25 CASE CONTROL STUDY: MEASURE OF ASSOCIATION Odds ratio Ill Not ill Exposed Not exposed a c b d OR = a c b d = a x d b x c
26 SALMONELLA OUTBREAK: MEASURE OF ASSOCIATION Odds ratio calculation for pork meat loaf Case Control Ate meat loaf x 35 OR = 1 x 3 = 105 Did not eat meat loaf 3 35 =
27 COHORT STUDY: MEASURE OF ASSOCIATION Calculating relative risk RR Ill Not ill Attack rate Relativ risk Exposed Not exposed a b a / (a+b) c d c / (c+d) a / (a+b) c / (c+d) Ref.
28 SALMONELLA OUTBREAK: CASE-CONTROL RESULTS Ready-made meal - 83 % of cases versus 28 % of controls Pork meat loaf: - 75 % of cases versus 3 % of controls Unmatched analyses - Ready-made meal OR=13 (95% KI: ) - Pork meat loaf from supermarket chain A: OR= 105 ( )
29 CONSUMER CARD INVESTIGATION - Collected for 6 patient households 3 months prior to disease onset Text from receipts No of patient household who bought it (n=6) Pork meat loaf brand X 4 Apples 5 Bananas 4 Cream 4 Æbleskiver 20stk 5 Clementines 1kg 4
30 FOOD INVESTIGATION Samples - Food and Veterinary Administration Pork meat loaf from 2 patients homes Two samples from producer (other production dates) - Producer 28 samples from recalled products Trace-back - 1 or more batches of meat loaf sold from December 2016 in supermarket chain A All samples were negative for salmonella!!
31 STEPS IN AN OUTBREAK INVESTIGATION 1. Confirm outbreak 2. Confirm diagnosis 3. Make a case definition 4. Identify cases and obtain information 5. Describe data: time, place, person 6. Develop hypothesis 7. Test hypothesis: Analytical studies 8. Implement control measures 9. Communicate results
32 WEEK OF SAMPLE FOR PATIENTS N=21 Recall of the product
33 Ekstrabladet
34 COMMUNICATION Outbreak report International communication SSI.dk
35 CHALLENGES IN OUTBREAK INVESTIGATION Work against time Political/media pressure Don t have full information when you start (react on small signals) Interviews can be difficult - Food history hard to remember - Selective memory - Very ill/dead people In-depth epidemiological analyses often not possible (quick and dirty) Difficult to find pathogen in the food Hidden ingredients Unequal distribution in the food and difference in susceptibility Multiple sources We don t always find the source
36 TAKE HOME MESSAGE Outbreak investigation is an important part of the prevention of infectious diseases Outbreak investigation demands a close cooperation between different institutions Interviews and statistical tools are important components of epidemiological methods It is fun, informative and never predictable
37 IF YOU WANT TO KNOW MORE Control of Communicable Diseases Manual 20 th ed. Heymann D. Annual report on Zoonoses in Denmark 2016 Statens Serum Institut - Epi-Nyt/Epi-News (weekly bulletin) - Sygdomsleksikon - Overvågning i tal og grafer - Opklaring af fødevarebårne udbrud i DK European Centre for Disease Prevention and Control - Communicable disease threats report (weekly) - EPIET training - Eurosurvelliance (Rapid communications) World Health Organization - Disease outbreak news
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