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Introduction A Challenge for the Disease Detective
What is an Outbreak? Uncovering Outbreaks
Why Investigate Outbreaks?

Why Investigate Outbreaks?

Health departments investigate suspected outbreaks for a variety of reasons. These include the need to institute control and prevention measures, the severity of the problem and its risk to others, the opportunity for research and training, program considerations, and public relations, political concerns, and legal obligations.

Control and prevention. A primary reason for a public health investigation is to control the outbreak at hand and prevent future outbreaks. In any investigation, you have to strike a balance between these two goals, depending on where the outbreak is in its natural course: Are cases occurring in increasing numbers or is the outbreak just about over?

If cases are continuing to occur, your first priority will more than likely be controlling the outbreak, so you want will to assess its extent and the characteristics of the population at risk so you can design measures to prevent additional cases. On the other hand, if an outbreak appears almost over, you may want to focus on investigating further to identify its source and using that information to develop measures that will prevent future outbreaks.

The balance between instituting control measures and conducting further investigation depends on how much you know about the agent causing the illness, the source of the agent, and its mode of transmission, since you cannot design control measures without this information.

Severity and risk to others. Decisions regarding whether and how extensively to investigate an outbreak are also influenced by the severity of the problem and its risk to others. It is particularly urgent to investigate an outbreak when the disease is severe and could affect more people unless prompt control measures are taken. For example, in the United States, every case of plague and botulism is investigated immediately to identify and eradicate the source. Cases of syphilis, tuberculosis, and measles are investigated promptly to identify contacts and interrupt transmission.

Research opportunities. Another important objective of outbreak investigations is simply to gain additional knowledge. Each outbreak offers a unique opportunity to study the natural history of the disease in question—including the agent, mode of transmission, and incubation period. For a newly recognized disease, there is the opportunity to study the clinical spectrum of the illness. Investigators also attempt to characterize the populations at greatest risk and to identify specific risk factors.

Even with familiar diseases, investigators can learn more about the impact of control measures and the usefulness of new epidemiological and laboratory techniques. For example, an outbreak of measles in a highly immunized community provides a setting for investigators to study the effectiveness of vaccine, the effect of age at vaccination, and the duration of protection afforded by the vaccine (1).

Training opportunities. Investigating an outbreak requires a combination of diplomacy, logical thinking, problem solving, quantitative skills, epidemiological know-how, and judgment. These skills improve with practice and experience. For this reason, many investigative teams pair a seasoned epidemiologist with an epidemiologist-in-training, who gains valuable on-the-job training and experience while assisting in the investigation and control of the outbreak.

Program considerations. Health departments routinely use a variety of programs to control and prevent illnesses such as tuberculosis, vaccine-preventable diseases, and sexually transmitted diseases. By investigating an outbreak of a disease targeted by one of these programs, health departments may discover populations at risk that have been overlooked, failures in the program’s intervention strategy, changes in the agent causing the disease, or events beyond the scope of the program. This information can then be used to improve control and prevention efforts.

Public, political, or legal concerns. Public, political, or legal concerns sometimes override scientific concerns in the decision to conduct an investigation. Increasingly, the public has taken an interest in disease clusters and potential environmental exposures and has called upon health departments to investigate. Such investigations almost never identify a link between the disease and the suspected source (2,3). Nevertheless, many health departments have learned that it is essential to be "responsibly responsive" to public concerns, even if the concern has little scientific basis (4,5,6). They also see these instances as opportunities to educate the public. In some instances (e.g., a request by three or more workers to investigate workplace health and safety), investigations are required by law.

Next: Steps of an Outbreak Investigation

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