Canadian Field Epidemiology Program
Outbreaks and other EPI-AIDS
EPI-AIDs
EPI-AIDs are the provision of assistance by Field Epidemiologists in investigating
a public health issue. Field Epidemiologists have investigated close to 250
public health issues since 1975. Here are some recent examples:
E. coli O157:H7
outbreak in Walkerton, Ontario (2000)
In spring 2000, the largest outbreak of E. coli O157:H7 associated
with drinking water in Canada led to 1,346 reported cases of gastroenteritis,
65 hospital admissions, 27 cases of hemolytic uremic syndrome and 6 deaths
in Walkerton, Ontario. A Field Epidemiologist assisted the outbreak investigation
team in conducting a cross-sectional study to determine the impact of the
outbreak and the source of water contamination. It was found that heavy rains
accompanied by flooding led to well water contamination by surface water
polluted by infected cattle. The Walkerton outbreak led to a review of the
safety of ground water sources in Canada.
http://www.phac-aspc.gc.ca/publicat/ccdr-rmtc/00vol26/dr2620eb.html
Severe Acute Respiratory Syndrome (SARS) in Canada
(2003)
 The
World Health Organization issued a global alert on March 12, 2003 about Severe
Acute Respiratory Syndrome (SARS). The first severe infectious disease to
emerge in the 21st century, SARS is characterized by a severe and rapidly
progressing respiratory infection leading to acute respiratory distress syndrome.
By mid-May 2003, over 8000 probable cases and over 700 deaths have been reported
throughout the world. In the same period, close to 150 probable cases and
26 deaths had been reported from Canada, most of them from the Greater Toronto
Area. During the first three months of the outbreak, eight of the ten Field
Epidemiologists were involved in the investigation in Vancouver, Ottawa,
Halifax and Toronto conducting cluster investigations and descriptive epidemiology,
designing prevention and control guidelines, responding to public and media
inquiries and planning and implementing studies.
http://www.phac-aspc.gc.ca/publicat/ccdr-rmtc/03vol29/dr2911ea.html
http://www.phac-aspc.gc.ca/publicat/ccdr-rmtc/03vol29/dr2908ea.html
http://www.phac-aspc.gc.ca/publicat/ccdr-rmtc/03vol29/dr2908eb.html
Pneumonia outbreak in Nunavut (2000)
In the fall of 2000, severe community-acquired pneumonia was reported in
several communities on Baffin Island, Nunavut. A Field Epidemiologist conducted
an epidemiologic investigation to describe the extent of the public health
problem. Ninety-two persons met the case definition. The clinical and radiographical
pattern suggested a bacterial origin, but only three cases had microbiological
confirmation, two of which were Streptococcus pneumoniae. The identification
of etiologic agents is a continuing challenge in Nunavut and other northern
communities where laboratory confirmation is often not available. Data from
this investigation supported the decision to implement a catch-up program
for their publicly-funded 23-valent pneumococcal polysacharride immunization
program and implement a 7-valent conjugate pneumococcal immunization program.
Ongoing surveillance for invasive serotypes of S. pneumoniae will
be crucial to the evaluation of immunization programs and to monitor any
shifts in the major serotypes causing disease in northern communities.
http://www.phac-aspc.gc.ca/publicat/ccdr-rmtc/02vol28/dr2816eb.html
Aspergillus in a surgery unit of a New Brunswick hospital
(2002)
Six patients undergoing heart valve replacement surgery in 2001-02 in a New
Brunswick hospital had Aspergillus cultured from their excised heart
valves. Prosthetic endocarditis and systemic aspergillosis were a real risk
in these patients. A Field Epidemiologist assisted in an investigation to
determine the extent of the outbreak and the cause of contamination. Environmental
investigations revealed fungal and mould contamination of the operating rooms
(OR). Contamination of the OR air supply was likely a combination of structural
defects in the ventilation system and concurrent external construction. There
was also a possibility of hospital laboratory contamination. Around the same
time, an aspergillosis outbreak was occurring in a Quebec hospital, resulting
in at least five deaths among individuals who underwent open chest surgery.
These two outbreaks increased the awareness of the risk and severity of nosocomial
aspergillosis and led to the implementation of strict infection control guidelines
and monitoring.
Norwalk-like virus outbreak on a cruise ship on the
West Coast (2001)
In June 2001, Health Canada received a report of excess gastrointestinal
illness aboard a cruise ship arriving from Alaska 24 hours prior to its arrival
in Vancouver, British Columbia. Fifty-four of 1576 (3.4%) passengers and
crew were ill with diarrhea and vomiting. Two Field Epidemiologists participated
in the investigation to determine the cause and source of the outbreak. The
causal agent was Norwalk-like virus. The exact source was not identified,
but the investigation suggested that the disease was transmitted person-to-person.
Aggressive cleaning and sanitation measures were implemented and educational
messages developed which led to the control of the outbreak.
Mesothelioma cluster in Ontario (1997-98)
In 1997, in a region of Ontario, a concerned citizen identified a potential
cluster of cases of mesothelioma. Two Field Epidemiologists participated
in the investigation to determine whether rates were truly elevated. Case
finding through the provincial cancer registry and the worker's compensation
registry revealed 35 cases among males. This was four times the expected
number, as compared with previous years. Because of asbestos manufacturing
in the region, it was thought that most cases were related to occupational
exposure. In-depth exposure ascertainment is being planned.
Health outcomes of a severe ice storm in Ontario
(1998)
The worst ice storm in recent memory struck Ontario, Quebec and New Brunswick
in January 1998. Nearly double the annual total of freezing rain fell in
the week of the storm and resulted in loss of electrical power and extremely
icy conditions. Many were put at risk of injury and illness. A Field Epidemiologist
was asked to describe the adverse health events related to the storm in one
health unit in Eastern Ontario. As compared to a similar period during the
previous year, an increase was noted in emergency room visits for carbon
monoxide poisoning and injuries due to falls. There was also an increase
in admissions for myocardial infarctions, gastrointestinal illness and fractures.
In general, increases were less than expected. Recommendations focused on
means to prevent the risk of carbon monoxide poisoning associated with alternate
sources of home heating.
 Syndromic
surveillance during World Youth Days in Toronto (2002)
Over 200,000 Catholic youth from around the world gathered in Canada from
July 13 to 22 and in Toronto from July 23 to 28, 2002 for World Youth Days
and a visit to Toronto by Pope John Paul the Second. Syndromic surveillance
was used for the first time in Canada to systematically monitor communicable
diseases, environment-related illness (e.g. heat stroke) and A-list bioterrorism
agents. Fourteen current and former Field Epidemiologists were involved in
national and Toronto-based surveillance activities for this mass gathering
event. Many heat-related illnesses occurred and a cluster of S. aureus food
poisoning was identified among 18 pilgrims. Syndromic surveillance identified
the outbreak and permitted rapid investigation and control.
Teaching outbreak investigation skills in New Brunswick
and in Alberta (2002-2003)
Following an outbreak of E. coli O157:H7 in New Brunswick, the provincial
government asked the CFEP and the Waterborne, Foodborne and Zoonotic Infections
Division to help them design and implement a two-day workshop on enteric
outbreak investigation for frontline public health workers in 2002. A second-year
Field Epidemiologist and the CFEP Director participated in the development
of the curriculum and the training of close to 100 public health inspectors
and nurses in both official languages. A similar training was conducted in
Alberta in 2003.
International EPI-AIDs
Field Epidemiologists are occasionally invited to participate in international
missions through the World Health Organization
(WHO) or other international partners. Recently, Field Epidemiologists
have participated in:
Needs assessment among Kosovar refugees in Macedonia
(1999)
 During
the war in Kosovo in 1999, under the direction of the United
Nations High Commission for Refugees (UNHCR), the CFEP sent a Field Epidemiologist
and the Program Director to Skopje, Macedonia. They participated in the planning
of a health needs assessment survey among refugees hosted by Macedonian families.
Teaching computer skills to public health workers in
Kosovo (2001)
As part of the Canadian Public Health Association's
(CPHA) health information mission in Kosovo, two Field Epidemiologists
traveled to the Prizreni Region in April and May 2001 to teach basic computer
skills, including MS Windows and EpiInfo, to Kosovar health professionals.
 Ebola
outbreak investigation in Uganda (2000)
Three second-year Field Epidemiologists and the CFEP Director joined an international
team of experts in Uganda in December 2000 to assist the Ugandan government
in the control of an Ebola Hemorragic Fever outbreak. They participated in
surveillance activities including setting up a surveillance database, active
case finding and descriptive epidemiology.
http://www.phac-aspc.gc.ca/publicat/
ccdr-rmtc/01vol27/dr2706eb.html
Ebola outbreak investigation
in Gabon (2001-02)
From December 2001 to January 2002, a second-year Field Epidemiologist joined
an international team of experts in Gabon to assist the Gabonese government
in the control of an Ebola Hemorragic Fever outbreak. She participated in
surveillance activities, case finding, follow-up of contacts and educational
sessions.
http://www.who.int/wer/pdf/2003/wer7826.pdf
Stop the Transmission
of Polio (STOP)
 STOP is
an international initiative assisting the WHO in the Global Polio Eradication
Initiative. Field Epidemiologists have participated in STOP missions through
the Canadian Public Health Association (CPHA),
the Centers for Disease Control and Prevention
(CDC) and the World Health Organization
(WHO). Their role has been to assist local governments in their polio
eradication and measles elimination efforts through surveillance for acute
flaccid paralysis, polio and measles and immunization activities. Since 1999,
Field Epidemiologists have participated in STOP missions in seven different
countries.
Bangladesh (1999)
Pakistan (2000)
Sudan (2000)
Gabon (2001)
Haiti (2001)
Bangladesh (2002)
Sudan (2002)
Senegal (2003)
How to Request Field Epidemiology Assistance
The CFEP offers epidemiological assistance by deploying Field Epidemiologists
to the field upon request. Field Epidemiologists can assist with the following:
- Outbreak investigation and control
- Cluster investigation and control
- Environmental risk assessment
- Surveillance activities
- Field epidemiology studies (descriptive epidemiology, needs assessments,
vaccine effectiveness, case control studies, cohort studies)
- Teaching and training in outbreak investigation, Epi Info, surveillance,
field epidemiology
Any Canadian region, province, territory or federal group investigating
a public health issue may request Field Epidemiology assistance (EPI-AID)
by consulting The
CFEP Procedures for Requesting and Undertaking Field Investigations.
Requests from health care facilities, local and regional health departments
should be directed to the Chief Medical Officer of Health of the province
or territory. Provinces, territories, federal divisions, departments and
agencies should contact the CFEP staff directly (contact
us).
The request for field epidemiology assistance (EPI-AID) is assessed by
the CFEP directors. If the EPI-AID is approved, terms of reference for the
Field Epidemiologist are negotiated with the organization requesting assistance.
Negotiation usually includes co-authorship on any publication arising from
the investigation. All data collected during the EPI-AID are the property
of the organization requesting assistance.
A Field Epidemiologist can usually be deployed to the field within 24 and
48 hours.
All costs associated with the Field Epidemiologist's work on an EPI-AID
are covered by the CFEP, including travel, accommodation and per diem.
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