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ONE HEALTH MANUAL
ON HANDLING ZOONOTIC
DISEASE OUTBREAKS IN MALAYSIA
This manual is made possible by the generous support of the American people
through the United States Agency for International Development (USAID). The
contents are the responsibility of the Malaysia One Health University Network un-
der the Emerging Pandemic Threats 2 One Health Workforce Project and do not nec-
essarily reflect the views of USAID or the United States Government. USAID re-
serves a royalty-free nonexclusive and irrevocable right to reproduce, publish, or
otherwise use, and to authorize others to use the work for Government purposes.
Published by
NATIONAL COORDINATING OFFICE (NCO)

MALAYSIA ONE HEALTH UNIVERSITY NETWORK (MYOHUN)
Faculty of Veterinary Medicine
Universiti Putra Malaysia
43400 Serdang, Selangor
Malaysia
Phone : +603-8609 3476 /3477 /3478
E-Mail: [email protected]
Website: http://www.myohun.com
Design and Printing by

ACE DESIGN & PRINTING
No.5, Jalan Putra 1, Taman Sri Putra,
Kempas, 81200 Johor Bahru, Johor, Malaysia.
Tel: +6016-608 4808 / +607-562 6264
Fax: +607-554 3144
E-mail: [email protected]
All rights reserved.

Copyright © Malaysia One Health University Network (MyOHUN)
Design © Ace Design & Printing
Readers are free to reproduce any part of this book by just acknowledging Malaysia
One Health University Network (MyOHUN) as the source.
First Print 2017
Perpustakaan Negara Malaysia Cataloguing-in-Publication Data
Chief Editor, Abdul Rashid Khan,

One Health Manual On Handling Zoonotic Disease Outbreaks in Malaysia
ISBN 978-967-960-416-0
CONTENTS
CHAPTER TOPIC PAGES
Introduction One Health Manual 1
1 Preparations for an Outbreak 19

Investigation
2 Establish and Verify Diagnosis 29
3 Laboratory Involvement 45
4 Developing, Evaluating and Refining 67

Hypotheses
5 Implementation of Control Measures 85
6 Communication During Outbreak 101

Investigations
Appendices 117
Index 148
FOREWORD BY DIRECTOR-GENERAL,
MINISTRY OF HEALTH MALAYSIA
FIRST, I wish to congratulate the members of the multisectoral and multidisciplinary team
from government agencies and the universities, working under the Malaysia One Health Uni-
versity Network (MyOHUN), for initiating and successfully completing this novel Manual.
This One Health Manual is a much needed, and welcome addition, to the existing guide-
lines and manuals on outbreak management in our country. I believe that this is the first
local Manual that deals with zoonoses outbreak investigation based on the One Health
paradigm. While the general concepts of One Health are now better known and accepted,
how to implement the One Health concept is still not clearly understood. The Manual’s
strength lies in its transdisciplinary (and not just interdisciplinary or multidisciplinary)
and multisectoral approach to the surveillance, prevention, investigation and control of
zoonoses. It is hoped that this Manual will address, to some extent, the numerous issues
and barriers related to implementation of One Health, thereby bridging the gap between
concept and implementation.
Users of this Manual should first read the Introduction to gain a quick understanding of
the One Health Paradigm, as well as its history and development. The six Chapters of
the Manual cover the following topics: (1) Preparations for outbreak investigation, (2)
Establish and verify the diagnosis of zoonotic diseases, (3) Laboratory involvement, (4)
Developing, evaluating and refining hypotheses, (5) Implementation of control measures,
and (6) Communication during outbreak investigations. The authors have done their best
to address the topics based on the One Health concept.
I am confident that by following the recommendations in this Manual, we will improve

the way we manage zoonoses outbreaks, many of which have occurred in Malaysia. We
were affected by the Nipah virus outbreak in 1998, Severe Acute Respiratory Syndrome
(SARS) in 2003, influenza A(H1N1)pdm pandemic in 2009, brucellosis in 2011/2012,
rabies in 2015, while leptospirosis has become endemic in our country. Meanwhile, avian
influenza continues to smoulder in the region. Our experiences in managing the human
health aspects of these zoonoses, have highlighted the need for more horizontal interaction
and cooperation among the disciplines and the sectors of the agencies, departments, min-
istries and academia that are responsible for public health, medical professions, veterinary
services, and the environment.
Making One Health operational provides an excellent opportunity for convergence and
synergy between the priorities of the human health, and the animal health sectors. In Ma-
laysia, much work still need to be done to address the seven Essential issues and challeng-
es for putting One Health into practice, and the five steps listed in the Way Forward section
of the Introduction of this Manual.
Finally, I suggest that MyOHUN collect feedback from users of this Manual, so that short-
falls can be addressed and improvements made to future editions.
DATUK DR. NOOR HISHAM BIN ABDULLAH

DIRECTOR GENERAL
MINISTRY OF HEALTH MALAYSIA
IV
FOREWORD BY DIRECTOR-GENERAL,
DEPT OF VETERINARY SERVICES, MALAYSIA
“ONE HEALTH” is a concept that human health, animal health and ecosystems are
interdependent and bound to each other to work in harmony. If one component is imbal-
anced, then the others will be affected.
The One Health concept has been envisaged and implemented by the World Organi-
zation for Animal Health (OIE) since year 2000 as a collaborative global approach to
understanding the risks for human, animal and ecosystem health as a whole. Controlling
zoonotic pathogens at their animal source is the most effective and economic way of
protecting humans. These initiatives should be coordinated at the human–animal–eco-
systems interface and applied at the national level through the implementation of appro-
priate policies. Therefore, this Manual is a good initiative taken as a guide for working
collaboratively in handling zoonotic disease outbreaks efficiently and effectively.
Veterinary Services, play an essential role in the development and implementation of

policies to manage animal health risks. In protecting animal health and welfare, they
substantially contribute towards improving human health, as well as food safety and
security. For this reason, they need appropriate and effective methods to prevent and
control zoonotic disease outbreaks, and must be able to communicate and form collabo-
rations with a wide range of stakeholders, in order for efficient joint action to be taken.
Since animal is the main source of human pathogens, controlling all animal pathogens
at their animal source is the most effective and economic way of protecting people;
therefore collaborative and multi-sectoral and multidisciplinary approach, centred on the
concept of “One Health” is important to be realised. Being aware of health risks at the
human–animal–ecosystems interface is the cornerstone of their prevention and control.
It is high time that a Manual like this is developed to be used as a guide of how One
Health approach can be applied in zoonotic disease management.
DATO’ DR KAMARUDIN MD ISA

DIRECTOR GENERAL
DEPARTMENT OF VETERINARY SERVICES MALAYSIA
V
FOREWORD BY CHAIRMAN, MALAYSIA ONE
HEALTH UNIVERSITY NETWORK (MYOHUN)
EMERGING infectious and zoonotic diseases have been identified as a major threat to
the health of people and animals globally, and to the security of our food systems and the
environments. In the past few decades, several emerging infectious and zoonotic disease
outbreaks have occurred at an unprecedented rate, which resulted in suffering and death
of human and animals, and imposed enormous financial burden on society. The unique
nature of emerging infectious and zoonotic disease requires rigorous procedures involving
trans-disciplinary team; a team of many individuals from different specialties and exper-
tise. At present, there are various Standard Operation Procedures used by governmental
departments or ministries in handling disease outbreak. Malaysia One Health University
Network (MyOHUN) sees this opportunity as imperative to revise and introduce a com-
mon manual for the use of novice and for guidance of workers in the field to respond and
manage an emerging infectious and zoonotic disease outbreak.
This manual is a product of the joint efforts of MyOHUN members, a national network
under the umbrella of South East Asia One Health University Network (SEAOHUN)
dedicated in building capacity of the global health workforce to prevent, detect and re-
spond to emerging infectious and zoonotic diseases with the financial support from The
United States Agency for International Development (USAID) and in collaboration with
the University of Minnesota and Tuft University, USA. As the chairman of MyOHUN, I
sincerely hope that this manual will be used to train our students from the medical, veter-
inary and other related disciplines, and will provide ministerial officers and practitioner's
guide when handling emerging infectious and zoonotic diseases. I am humbled and am
extremely grateful to the contributors of this manual, led by Prof Abdul Rashid Khan and
team members from universities and ministries, for their time and determination leading
towards its completion. It is indeed a testament to the commitment of members of MyO-
HUN to the education and training of the current and future one health workforce on the
emerging infectious and zoonotic diseases. Thank you.
PROFESSOR DR MOHD HAIR BEJO

CHAIRMAN, MALAYSIA ONE HEALTH UNIVERSITY NETWORK
DEAN, FACULTY OF VETERINARY MEDICINE
UNIVERSITI PUTRA MALAYSIA
VI
PREFACE
TO ME, “One Health” connotes “multidisciplinary collaboration”. Although most are
aware with the term multidisciplinary but the concept of One Health is alien to some and
the idea of working in a multidisciplinary team disconcerting. This is not surprising con-
sidering it is human nature to fear things/concepts we are not familiar with. Interestingly
it was fear that triggered experts to appreciate the importance of coordinated collaboration
of a multidisciplinary team. The estimated 50 million deaths associated with the Span-
ish influenza at the end of the First World War triggered a worldwide fear of a pandemic
when HPAI H5N1 emerged. This resulted in the start of the One Health concept being
taken seriously by experts and governments. One Health has now progressed beyond the
“bird flu” and SARS pandemic threat to enclose other zoonotic diseases and beyond, in-
cluding climate change as a global threat.
The population of the world is increasing and it is inevitable that the interface between
humans, animals and environment becomes more intimate. Because of the increased hu-
man-animal interaction, compounded by the increasing land use, changes in climate and
international trade and travel, the risk of exposure to new and existing pathogens also in-
creases incrementally. Because both humans and animals carry many similarities there is
a real risk of infections originating from either. Hence it is pertinent that we are aware of
the similarity and interconnectivity of these two species health in planning and preventing
global disease prevention measures. With the increase in awareness, knowledge and un-
derstanding of the interdependency of the human, animal and environment interaction, the
One Health concept is now gaining momentum in the world.
Although One Health is generally considered as a new concept but the foundation had
been laid long ago with Hippocrates work in “On Airs, Waters and Places”. In the 1800’s
Rudolf Virchow succinctly described this concept - “Between animal and human medi-
cine there is no dividing line—nor should there be. The object is different but the experi-
ence obtained constitutes the basis of all medicine.” But not until the 1980’s, when epide-
miologist Calvin Schwabe called for a unified human and veterinary approach to combat
zoonotic diseases, was the modern foundation for One Health laid. But it took almost an-
other three decades before the American Veterinary Medical Association and the Ameri-
can Medical Association adopted the concept. The idea and concept has now grown large
and many international organizations including the Food and Agriculture Organization of
the United Nations (FAO), the World Health Organization (WHO), the World Organisa-
tion for Animal Health (OIE), the United Nations Children’s Fund (UNICEF), the World
Bank, and the United Nations System Influenza Coordination (UNSIC) have adopted the
principles of One Health.
In the search for the most appropriate definition of One Health, I found a myriad, but
all of which point to a common theme - collaboration. The importance of collaboration
cannot be emphasized enough, collaboration increase the thought process, effectiveness,
optimize resources and break down the practice and mentality of working in silos and en-
ables the building of new networks and expanding of existing ones among professionals
through multidisciplinary communication, cooperation, and collaboration.
VII
Outbreak investigations which are a component of epidemiology and public health, are
not only important for immediate identification of the source of the outbreak but also to
prevent future outbreaks by increasing the knowledge and skills of the persons involved
in the investigations. In most instances, outbreak investigation requires individuals with
different background to be effective. Hence outbreak investigation provides a unique op-
portunity for collaboration, training and cooperation between the people with different
disciplines i.e. a One Health team. Internationally, One Health teams usually comprise of
physicians, veterinarians, wildlife specialists, environmentalists, anthropologists, econo-
mist and sociologist. This eclectic group is the best means of controlling infectious diseas-
es including zoonotic infections some of which have a potential to cause extensive human
morbidity and mortality, however this concept is still novel within Malaysian.
We are cognizant that there are many standard operating procedures to investigate and
control infectious diseases but all are very specific to each discipline. Hence this project
provided a unique opportunity to create a manual to encompass the One Health concept in
an interdisciplinary team collaborating to investigate an outbreak and provide an avenue
to educate existing and future One Health workforce.
This manual was prepared by a multidisciplinary team; for some this was a first experi-
ence working in an One Health team. The exercise of preparing this manual provided us
with the opportunity to understand each other’s invaluable role in zoonotic disease pre-
vention and control. It is our fervent hope that the users of this manual will benefit from
it and become productive one health members in the prevention and control of zoonotic
infections. This manual is not meant to replace existing manuals/standard operating pro-
cedures available but rather to complement and provide opportunities for field workers to
consider all aspects of disease control. The content of this manual was taken from many
sources which we have cited, we encourage the user to refer to these sources for further
reference. Considering this user friendly multidisciplinary One Health manual on han-
dling disease outbreaks is the first of its kind, we look forward to feedbacks and sugges-
tions for improvement in the future edition.
‘It is not the strongest of the species who survive, nor the most intelligent; rather it is
those most responsive to change’ (Charles Darwin).
One Health is an important response to change, change to the way we respond to emerg-
ing and remerging infectious diseases. Our survival depends on it!
PROF DR ABDUL RASHID KHAN

CHIEF EDITOR
VIII
ACKNOWLEDGEMENTS
WE WOULD like to thank USAID and MyOHUN, especially Prof Dr Mohd Hair Bejo
the chairman of MyOHUN and Assoc. Prof Dr Latiffah Hassan, coordinator MyOHUN
for the support and the encouragement as well as for their vision in supporting this inno-
vative endeavour.
We would like to thank Prof Stanley Gordon Fenwick for his advice and suggestions in
the development of the Manual.
We would also like to thank our employers for their understanding and support:
Department of Veterinary Services Universiti Kebangsaan Malaysia

Institute for Medical Research University of Malaya
International Medical University Universiti Malaysia Sarawak
Johor Bahru Health Office Universiti Malaysia Sabah
Kuala Lumpur City Hall Universiti Putra Malaysia
Ministry of Health, Malaysia Universiti Sains Malaysia
National Public Health Laboratory Universiti Teknologi MARA
Penang Medical College Veterinary Research Institute
Sarawak Health Department
We would also like to extend our gratitude to Mr Raja Khairul Adli Bin Raja Kamalz-
aman and his MyOHUN National Coordinating Office team for their invaluable help in
making this project a success.
Finally I would like to congratulate and thank the team in making this experience pleasant
and educational for me personally. It may be small, but all of us have played a part in the
Global Health Security Agenda.
IX
LIST OF ABBREVIATIONS
AAHL - Australian Animal Health Lab

ACD - Active case detection
ADIC - Animal Disease Information Centre
AIV - Avian Influenza Virus
AMA - American Medical Association
AMRO - Assistant Medical Record Officer
AMT - Alert Management Team
AR - Attack Rate
AVMA - American Veterinary Medical Association
BSL - Biosafety lab
CI - Confidence interval
DFAT - Direct Fluorescent Antibody Test
DG - Director General
DHO - District Health Office
DNA - Deoxyribonucleic acid
DVS - Department of Veterinary Services
ELISA - Enzyme Linked Immunosorbent Assay
FAO - Food and Agricultural Organization
HA (genes) - Hemagglutinin
HAZMAT - Hazardous Material Team
HPAI - Highly pathogenic avian influenza
ICU - Intensive Care Unit
IHR - International Health Regulations
ILI - Influenza Like Illness
IMR - Institute of Medical Research
IV - Intravenous
MAT - Microscopic Agglutination Test
OHW - One Health Workers
OIE - Office of International Des Epizooties
(World Organization for Animal Health)
OR - Odds Ratio
OWOH - One World One Health
PCR - Polymerase chain reaction
X
PERHILITAN - Department of Wildlife and National Parks
PHEICs - Public Health Emergencies of International Concern
PPKP - Assistant Environmental Health Officer
PUO - Pyrexia of unknown origins
RAT - Rapid Action Team
RBPT - Rose Bengal Plate Test
RR - Relative Risk
RRT - Rapid Response Team
RTPCR - Reverse transcription polymerase chain reaction
SPS - Sanitary and Phytosanitary
STI - Sexually Transmittable Illnesses
UNICEF - United Nations International Children’s Emergency Fund
VRI - Veterinary Research Institute
WHO - World Health Organization
XI
CHIEF EDITOR
Prof Dr Abdul Rashid Khan MBBS, MHSc, PhD
Penang Medical College
Deputy Dean, Post Graduate Affairs and International Relations
Head, Department of Public Health Medicine
Director, University College Dublin MSc Public Health in Penang Medical College
Email: [email protected]
EDITORIAL TEAM
Dr Andrew Kiyu, MBBS, MPH, DrPH, AM, FACE
Consultant epidemiologist,
Sarawak Health Department.
Dr Khebir bin Verasahib, MD, DAP&E, MPH (Epid)

Public Health Physician
Director
National Public Health Laboratory
Associate Professor Dr Rukman Awang Hamat, MBBS, MPATH

(Medical Microbiology)
Clinical Microbiologist
Department of Medical Microbiology and Parasitology
Faculty of Medicine and Health Sciences
Dr Ramlan bin Mohamed, PhD

Chief Deputy Director
Division of Research and Innovation
Department of Veterinary Services
Assoc. Prof Dr Razitasham Safii, MBBS, M. Comm Health

Department of Community Medicine and Public Health
Universiti Malaysia Sarawak
Dr. Moniza Waheed, B Comm, MA, PhD

Department of Communication
Faculty of Modern Languages and Communication
XII
Dr Rosnah Ismail, MBBS, PgDip.OH, MPH, DrPH
Occupational Health Unit, Community Health Department, Faculty of Medicine, UKM
CONTRIBUTORS
Introduction


Director
Dr Rozanah Asmah Abu Samad, DVM, PhD

Veterinary Officer
Email:[email protected]
Dr Azizah Darus, DVM

Veterinary Officer
Veterinary Research Institute
Dr Badrul Hisham b Abd Samad, MBBS, MPH, MEE

Johor Bahru Health Office
Dr Sarah Dadang Abdullah, DVM, MSc, PhD

Veterinary Officer
Department of Veterinary Service
Prof Dr Abdul Rashid Khan MBBS, M HSc, PhD

Deputy Dean, Post Graduate Affairs and International Relations
Head, Department of Public Health Medicine
Director, University College Dublin MSc Public Health in Penang Medical College
XIII
Chapter 1

Director
Dr Rozanah Asmah Abu Samad, DVM, PhD

Veterinary Officer
Dr Azizah Darus, DVM

Veterinary Officer
Dr Badrul Hisham b Abd Samad, MBBS, MPH, MEE

Johor Bahru Health Office
Dr Sarah Dadang Abdullah, DVM, MSc, PhD

Veterinary Officer
Department of Veterinary Service
Chapter 2
Dr John T Arokiasamy, MBBS, MPH, MSc Epidemiology
Professor and Head,
Department of Community Medicine, International Medical University, Kuala Lumpur.
Dr Rosnah Ismail, MBBS, PgDip.OH, MPH, DrPH

Occupational Health Unit, Community Health Department, Faculty of Medicine, UKM
XIV
Dr Seng Fong Lau, DVM, PhD
Department of Veterinary Clinical Studies, Faculty Of Veterinary Medicine, UPM
Dr Ahmad Filza Ismail, MD, M Comm Med, Certificate in Aerospace Medicine,

Fellow of Alumni Doctor USM (FADUSM), Occupational Health Doctor (OHD)
Medical Lecturer,
Department of Community Medicine,
School of Medical Sciences, Health Campus USM
Dr Nurul Syuhada Bt Zainal Abidin, DVM

Abattoir Management Section, Downstream Industry Development Division,
Department of Veterinary Services, Putrajaya
Chapter 3
Dr Ramlan bin Mohamed, PhD
Chief Deputy Director
Division of Research and Innovation
Dr Fairuz Amran, MD, M Path

Infection Disease Research Centre, Bacteriology Unit,
Institute for Medical Research,
Kuala Lumpur
Associate Professor Dr Rukman Awang Hamat, MBBS, MPATH (Medical

Microbiology)
Associate Professor Dr Syafinaz Amin Nordin, MBBS, MPATH (Medical

Microbiology)
XV
Dr. Zurin Azlin Binti Md. Jinin, DVM
Veterinary Officer
Email: [email protected] or [email protected]
Dr Taznim Begam binti Mohd Mohidin, PhD

Division of Microbiology
Institute of Biological Sciences
Faculty of Science
University of Malaya
Associate Professor Dr Ariza Adnan, MBBS, M Path, FAMM

Deputy Dean (Academic and Student)
Consultant Pathologist (Medical Microbiology)
Faculty of Medicine
Universiti Teknologi MARA
Chapter 4
Associate Prof Dr Razitasham Safii, MBBS, M. Comm Health
Department of Community Medicine and Public Health
Universiti Malaysia Sarawak
Dr Mohammad Saffree Jeffree MD, M. Community Medicine (OH UKM),

CMIA, OHD, EIP
Community and Family Medicine Department
Universiti Malaysia Sabah
Dr Hayati binti Kadir @ Shahar, MBBch. BAO, M. Comm. Health

Department of Community Health
UPM Serdang, Selangor
Dr Akma Binti Ngah Hamid, DVM, MSc.

Department of Veterinary Services Selangor
Email: [email protected] or [email protected]
XVI
Dr Siti Zubaidah Ramanoon, DVM, MSc., PhD
Department of Medicine and Surgery of Farm and Exotic Animals
43400 UPM Serdang Selangor
Dr Sylvia Daim, BSc., MSc., PhD

Universiti Malaysia Sabah
Chapter 5
Associate Professor Dr Hidayatul Fathi Othman, BSc, MSc, PhD
Biomedical Science Programme
UKM
Dr. Zainol Ariffin bin Pawanchee, MD, MPH

Health & Environment Department
Kuala Lumpur City Hall
Dr. Yahasmida Yaacob

Department of Veterinary Sciences For The State of Selangor
Dr. Sharifah Salmah Syed Hussain DKNP, DVM, MVM, PhD

Department of Veterinary Clinical Studies,
Dr Siti Fatimah Kader Maideen, B Biomed, M MedSc, PhD

Lecturer, Department of Public Health Medicine
Dr Surajudeen Abiola Abdulrahman, MBBS, MHPM, PhD

Lecturer, Department of Public Health Medicine
XVII
Chapter 6
Dr. Moniza Waheed, B.Comm, MA, PhD
Department of Communication
Faculty of Modern Languages and Communication
Associate Professor Tengku Hanidza Tengku Ismail BSC, MSC

Department of Environmental Sciences
Faculty of Environmental Studies
Dr. Mohd Mokrish Md. Ajat BSC, MSC, PhD

Department of Veterinary Preclicinal Sciences
Dr Shaharom Noraziah Che Mat Din, MD, M Med (PH)

Makmal Kesihatan Awam Johor Bahru
Jalan Persiaran Tanjung, Tampoi
81200 Johor Bahru
XVIII
INTRODUCTION
ONE HEALTH MANUAL

Dr Andrew Kiyu, Dr Khebir bin Verasahib,
Dr Rozanah Asmah Abu Samad, Dr Azizah Darus,
Dr Sarah Dadang Abdullah, Dr Badrul
Hisham b Abd Samad, Prof Abdul Rashid Khan
ONE HEALTH MANUAL
Importance of the challenges posed by the spread of infectious diseases

The importance of the challenges posed by the spread of infectious diseases is evident in
the first sentence of the first paragraph of the Executive Summary of the Consultation
Document entitled Contributing to One World, One Health which was produced by five
United Nations agencies and The World Bank (2008) -
“Humanity faces many challenges that require global solutions. One of these
challenges is the spread of infectious diseases that emerge (or re-emerge) from
the interfaces between animals and humans and the ecosystems in which they
live. This is a result of several trends, including the exponential growth in hu-
man and livestock populations, rapid urbanization, rapidly changing farming
systems, closer integration between livestock and wildlife, forest encroach-
ment, changes in ecosystems and globalization of trade in animal and ani-
mal products.” (FAO, OIE, WHO, UNSIC, UNICEF & The World Bank, 2008)
A comprehensive literature review by Taylor et al (2001) identified 1,415 species of in-

fectious organisms which are known to be pathogenic to humans. Of these, 868 (61%)
are zoonotic, and 175 (12.4%) pathogenic species are associated with diseases that are
considered to be “emerging”. Of the emerging pathogens, 132 (75%) are zoonotic. Over-
all, zoonotic pathogens are twice more likely to be associated with emerging diseases than
non-zoonotic pathogens.
Further investigations into a variety of wildlife species revealed a plethora of new viruses
carried by fruit and insectivorous bats, rodents and other species of wildlife from around
the globe.
The SARS outbreak in 2003 showed that:

• a previously unknown pathogen could emerge from animal sources at any time and
in any place and, without warning, threaten the health, well-being and economies
of all societies;
• there was a clear need for countries to have the capability and capacity to maintain
an effective alert and response system to detect and quickly react to outbreaks of
international concern, and to share information about such outbreaks rapidly and
transparently.
Following the lessons learnt from the SARS and H5N1 outbreaks, WHO put together a
strategic action plan for pandemic influenza (2006 – 2007) which emphasized the need
for all countries to develop capacities to rapidly detect, contain, respond to, and cope with
such pandemics. Five strategic actions and corresponding goals that contribute to an over-
all objective of pandemic prevention and preparedness were suggested. (Table 1) The doc-
ument (WHO, 2006) is available at: http://www.who.int/csr/resources/publications/influ-
enza/StregPlanEPR_GIP_2006_2.pdf
2
INTRODUCTION
Table Introduction 1: Strategic action plan and goal
STRATEGIC ACTION GOAL

1. Reduce human exposure to the Reduce opportunities for human infection
H5N1 virus and, in so doing, reduce opportunities for a
pandemic virus to emerge
2. Strengthen the early warning sys- Ensure that affected countries, WHO, and the
tem international community have all data and
clinical specimens needed for an accurate risk
assessment
3. Intensify rapid containment opera- Prevent the H5N1 virus from further increas-
tions ing its transmissibility among humans or de-
lay its international spread
4. Build capacity to cope with a pan- Ensure that all countries have formulated
demic and tested pandemic response plans and that
WHO is fully able to perform its leadership
role during a pandemic
5. Coordinate global scientific re- Ensure that pandemic vaccines and antiviral
search and development drugs are rapidly and widely available, shortly
after the start of a pandemic and that scientific
understanding of the virus evolves quickly
Source: WHO (2006). p2
Thus Malaysia must develop the capability and capacity to be ever ready to face zoonotic
disease outbreaks, and be better prepared than we were during the Nipah virus outbreak in
1998/1999.
Following WHO’s advice, the Ministry of Health Malaysia (MOH, 2006) also put in
place structures (planning committee) and a policy document (interim national plan)
aimed at providing guidance and the capacity to adequately pre-empt, respond, and con-
tain such outbreaks through rapid, timely and coordinated inter-sectoral and inter-agencies
action. Six phases of pandemic preparedness and response were identified, with clearly
specified goals, and the responsible agencies/personnel including public health, medical,
laboratory, risk communication and pharmaceuticals. This action plan and steps are de-
tailed on pages 24 to 42 of the National Influenza Pandemic Preparedness Plan (2006),
available at: http://jknns.moh.gov.my/v1/images/borang/cdc/s.National%20Influenza%20
Pandemic%20Preparedness%20Plan.pdf
The objectives of the national influenza surveillance system are to:

a. detect increased influenza activities, either epidemic or pandemic through:
» detection of influenza-like illness (ILI) in the community using sentinel general/
primary medical practices;
3
ONE HEALTH MANUAL
» the use of laboratory confirmation of influenza infection to estimate the propor-

tion of these cases that are due to influenza;
» viral isolation to confirm the diagnosis and to provide strains for antigenic anal-
ysis in WHO Influenza Reference Laboratory for vaccine formulation and to de-
tect new strains.
b. rapidly detect and confirm any case due to potential or actual pandemic strains
known to be present overseas, as identified by WHO or other suitable sources in-
cluding strains found in animal populations that may pose a threat to humans.
c. detect and identify in a timely manner new strains that may arise in Malaysia.
d. enhance the level of surveillance if a pandemic strain is identified outside and inside
Malaysia.
While the above guidelines were specific for influenza control, the One Health Paradigm
builds on these and emphasises a trans-disciplinary approach in prevention and response
to all zoonotic diseases outbreak.
In order to deal with zoonotic outbreaks effectively, Malaysia needs to move from the
current siloed approach to a trans-disciplinary approach, namely the One Health par-
adigm. This is necessary because many emergent pathogens are not only linked to in-
creasing contact between humans and animals, both domestic and wild, but also to the
intensification and integration of food production, to the need for clean drinking water,
to climate, and to the expansion of international travel and trade. The role of the wild-
life-livestock-human-ecosystem interfaces has been fundamental to the development of
the One Health paradigm over the past decade, a concept that recognizes that the health
of humans, animals, and ecosystems are interconnected, and that to better understand and
respond to zoonotic diseases requires coordinated, collaborative, multidisciplinary and
cross-sectoral approaches.
“One World One Health” or “One Health”

“One World – One Health” was coined by the Wildlife Conservation Society and in 2004,
The Manhattan Principles were developed as a result of an interdisciplinary symposium
addressing the relationships between human, domestic animal and wildlife health. The
Manhattan Principles are composed of 12 recommendations that focus on the prevention
of zoonotic disease and the maintenance of biodiversity.
The Manhattan Principles of the Wildlife Conservation Society (2004) states that:
“It is clear that no one discipline or sector of society has enough knowledge and
resources to prevent the emergence or resurgence of diseases in today’s globalized
world. Only by breaking down the barriers among agencies, individuals, specialties
and sectors can we unleash the innovation and expertise needed to meet the many
serious challenges to the health of people, domestic animals, and wildlife and to
the integrity of ecosystems. We are in an era of “One World, One Health” (OWOH)
and we must devise adaptive, forward-looking and multidisciplinary solutions to
the challenges that undoubtedly lie ahead” (http://www.oneworldonehealth.org).
4
INTRODUCTION
In June 2007, The American Medical Association (AMA) passed the One Health Resolu-
tion Promoting Partnership between Human and Veterinary Medicine. On July 3, 2007,
the House of Delegates of the AMA unanimously approved a resolution calling for in-
creased collaboration between the human and veterinary medical communities. The term
One Health was used in this Resolution. Thus, in this document, the term “One Health” is
used instead of “One World One Health” or any other similar terms.
History of One Health

In common with many other writers on One Health, Mackenzie, McKinnon and Jeggo
(2014) wrote:
“The concept of One Health is not new; the recognition that the health of people,
animals and the ecosystems of which we are part, are inextricably woven togeth-
er and is as old as human culture (Veterinarians Without Borders 2010). Over
2,500 years ago Hippocrates urged physicians that all aspects of their patients’
lives need to be considered including their environment. However, the concept has
been more commonly associated with the nineteenth century physician Rudolf Vir-
chow, who acknowledged the similarities between human and animal medicine,
and who first used the term ‘zoonosis’ for infections acquired from animals.”
Much more recently in the mid-1960s, the eminent American veterinary epidemiologist,
Calvin Schwabe, also recognized that the health of humans, animals and ecosystems are
interconnected, which he referred to as “One Medicine” in his textbook “Veterinary Medi-
cine and Human Health” .
The significance of zoonoses in the emergence of human infectious diseases was also rec-
ognized in the 1992 Institute of Medicine Report ‘Emerging Infections: Microbial Threats
to Health in the United States’, and the subsequent 2003 Report ’Microbial Threats to
Health: Emergence, Detection, and Response’. These and a number of subsequent meet-
ings and events have been instrumental in further developing and defining the One Health
paradigm.
Appendix Introduction 1 lists the major milestones in the development of One Health.
Definitions and Scope of One Health

There is no single, accepted definition of One Health, but the most frequently used defini-
tion is that developed by the American Veterinary Medicine Association (AVMA):
“The integrative effort of multiple disciplines working locally, nationally, and

globally to attain optimal health for people, animals and the environment.”
The breadth and scope of One Health makes it difficult to find a definition that covers all
aspects, and indeed the lack of consensus gives the One Health approach much greater
flexibility .
5
ONE HEALTH MANUAL
Stephen and Stitt (2009) view the situation as follows:
“There are two major camps with One World One Health. On one end are those
who focus almost exclusively on the goal of preventing pandemic zoonotic dis-
eases in people. At the other end are those who view OWOH as a continuum of
health risks and benefits from the environment through animals, to people (Fig-
ures Introduction 1 and 2). This latter view has many similarities to sustainability,
health promotion and ecohealth. Between these definitions is the recognition that
animals can contribute to public health outcomes in a variety of different ways.”
The opening statements of the report from an international consultation on One

World One Health held in 2009 in Winnipeg acknowledged that defining One
World One Health can be problematic. The meeting concluded that the One World
One Health concept, “provides a framework for preventing emerging infectious
diseases of animal origin, instead of simply responding to them once they have
occurred”. The meeting focused largely on human burdens of disease from epi-
demic zoonoses. Key recommendations of this meeting focused mostly on mecha-
nisms to foster cross-agency and cross-species knowledge transfer and exchange.
This is the concept of One Health that is adopted in this manual, because “there is
a general agreement, especially in national One Health programmes, of the need
to focus on the animal-human infectious diseases interface as ‘doable’ whilst ex-
tending activities to develop infrastructure and capacity to a broader approach”.
Figure Introduction 1. The One Health concept recognizes the interrelationship between
animal, human, and environmental health
Source: Adapted from Mazet, J., H. McDermott, and T. Goldstein (2015).
6
INTRODUCTION
Figure Introduction 2. The One Health concept promotes interdisciplinary collaborations

to solve complex health problems.
Source: Adapted from Mazet, J., H. McDermott, and T. Goldstein (2015).
Zoonoses Outbreak Investigations Based on One Health Paradigm

Preparations are needed to be put in place before zoonoses outbreak investigations based
on One Health Paradigm become a reality. The One Health paradigm aims for two things:
(1) changing the organisation of work from vertical or segmented to horizontal i.e. across
disciplines, and (2) the need to move from a “siloed” to a trans-disciplinary or trans-sec-
toral approach.
Outcomes from the One Health paradigm

Adopting the One Health paradigm will enable:
• shared surveillance to improve the capability to detect the emergence of a disease
event, thus fulfilling a prescription set forth in the International Health Regulations.
• the preparation of joint strategies for prevention and control, clearly defining roles,
responsibilities, and accountabilities.
• joint preparation and testing of emergency preparedness plans and the joint formu-
lation of internal and external reporting and communication plans.
• the sharing of facilities and exchanging of staff in surveillance and control operations
would foster capacity throughout the system’s membership.
• participating institutions to employ new modalities for mobilizing financial resources
• for joint planning and response to emergency and ongoing operating needs.
Currently, the division of labour among public institutions results in a segmented or vertical
organization of work, in which institutions operate independently of one another and from
the perspective of their discipline or sector. This unavoidably leads to gaps, and sometimes to
overlaps. For practitioners working in this framework, the starting point for action tends to re-
volve around the question “What am I responsible for?” rather than “What needs to be done?”
7
ONE HEALTH MANUAL
There is a need to change the organization of work across disciplines and start with the
question “What needs to be done?” This implies a substantial reorientation along horizon-
tal lines in which regular communication takes place between practitioners at work in dif-
ferent disciplines and sectors. This does not imply an amalgamation of work but rather the
creation of a culture in which practitioners are more likely to understand the significance
of a finding or event within their own field for practitioners in other fields. Figure Intro-
duction 3 presents these two orientations.
Working across disciplines means that One Health requires a trans-disciplinary ap-
proach, which implies an exchange of knowledge and skills between disciplines in work-
ing together for a desired outcome. On the other hand, “multidisciplinary” is defined as
many disciplines being involved and “inter-disciplinary” as disciplines working very
closely with one another and plans fully integrated .
Human Animal Tourism Trade Others Human Animal Tourism Trade Others
Health Health Health Health
Figure Introduction 3: Vertical and Horizontal Orientation

in Disease Prevention and Control
Source: The World Bank (2010), p26
Steps in Outbreak Investigation

A popular guide to outbreak investigation is the “Ten steps of a field investigation”. There
are a number of variations to the 10 steps, resulting in five, seven or 13 steps (Appendix
Introduction 2).
For the purpose of this Chapter, the most suitable guide is New Zealand’s Guidelines for
the Investigation and Control of Disease Outbreaks. Porirua: Institute of Environmental
Science & Research Limited; updated 2012. There are eight principal components of out-
break management as shown in Table Introduction 2. The connections between the eight
steps are shown in Figure Introduction 4.
8
INTRODUCTION
Table Introduction 2: Components of outbreak management

COMPONENTS AIMS
1 Preparation Optimal level of preparedness
Consistent and comprehensive collection and
2 Surveillance review of information on diseases with out-
break potential
OUTBREAK INVESTIGATION
Sensitive, specific and timely detection of po-
3 Confirmation and assessment
tential outbreaks with public health impact
Outbreak description, including Characterisation of outbreak to identify the im-
4 situational analysis and descrip- mediate need for control or hypotheses for fur-
tive epidemiology ther investigation
Full investigation
• Analytic epidemiological in- Identification of outbreak source, transmission
5 vestigation mechanisms, contributing factors and control
• Environmental investigation points
• Laboratory investigation
OUTBREAK RESPONSE
6 Outbreak control Prevent further disease transmission
Public and relevant agencies appropriately in-
7 Outbreak communication
formed and involved in outbreak management
8 Outbreak documentation Optimal dissemination of recommendations
Source: Institute of Environmental Science & Research Limited (updated 2012).
Developing plans to put One Health into practice

While there has been wide-ranging commitment to the One Health approach for address-
ing complex health problems by a large number of national and international organiza-
tions and professional bodies, its operationalization has so far proved to be challenging.
Implementation is often a complex issue requiring collaboration between diverse and
multidisciplinary partnerships. At a local or national level it is often a matter of breaking
down professional barriers through improved communication and incorporating informa-
tion on One Health and its benefits into professional training and university courses.
Malaysia is in the same situation as described above, especially since the One Health par-
adigm is relatively new here. It was introduced about five years ago in December 2011,
through the formation of SEAOHUN (South East Asia One Health University Network),
initially with 10 universities from four countries, Indonesia, Malaysia, Thailand and Viet-
nam.
One of the meetings directed at developing ways to put the concepts of One Health into
practice was an expert consultation entitled “One World, One Health: From Ideas to Ac-
tion”, sponsored by the Public Health Agency of Canada in 2009.
9
ONE HEALTH MANUAL
Preparation
Surveillance
Outbreak Investigation Outbreak Response
Confirmation
and Assessment
Outbreak
Control
Outbreak
Description
Full Investigation Outbreak

Communication
Analytic Epidemiology
Component
Environmental Outbreak
component Documentation
Laboratory
Component
Figure Introduction 4: Outbreak management framework: major elements
Source: Institute of Environmental Science & Research Limited (updated 2012), p13
It brought together scientific experts, international organizations and government offi-

cials to seek ways to advance the concept and build a framework for future activities. The
meeting made a number of recommendations including to:
a) foster political will
b) support partnerships and collaborations
c) encourage data sharing and integration
d) build capacity
e) develop communication strategies (include the media)
f) provide incentives for reporting adverse events;
g) encourage stakeholder and community engagement
h) develop ‘supra country’ (trans-border) approaches
These are the things that Malaysia also has to do if it is to advance the concept and the
practice of One Health in the country.
10
INTRODUCTION
Essential issues and challenges for putting One Health into practice
1. Leadership
Strong leadership is needed for the development of a One Health approach, and this is a
crucial issue that the country has to address. Leadership is essential for building relation-
ships and trust, both vertically within an organization and from community to internation-
al levels but most importantly horizontally between disciplines and within communities.
In Malaysia (as in many other countries), the sectors and disciplines needed to collab-
orate, for a One Health approach is based in different institutes, departments and min-
istries. Offering leadership in this complex environment is often seen as threatening or
“empire building”. On the contrary, the One Health approach is alliance-building towards
a trans-disciplinary approach to working, and leadership is crucial if the benefits of a One
Health approach are to be realized.
The lead Ministry as well as the designation of a leader must be identified. The World
Bank (2010) recommends that:
Unless countries find ways to institutionalize more permanent channels be-

tween their responsible line ministries and sector agencies, new coordina-
tion mechanisms will have to be built from scratch in the event of new in-
stitutions—that facilitate effective and efficient prevention, detection, and
control of zoonotic and other diseases of national or international significance.
Depending on the capacity of public institutions within a country, a number of options are
available.
• Creating a special permanent cross-sectoral coordination mechanism (which
could have several working groups), either through the exchange of memoranda
of agreement between the different ministries and agencies involved, the pri-
mary responsibility of which is to prepare prevention strategies and regularly
update contingency plans to address eventual new or re-emerging outbreaks.
• Establishing a coordinating authority at the executive level of government, such
as at the prime minister or deputy prime minister level, to which the agencies
responsible for public health, veterinary services, and the environment must all
report. This may take the form of a task force assigned to define an integrated
strategy, oversee the preparation of contingency plans, and ensure their full
implementation.
• Establishing special One Health teams composed of representatives of the
human, animal, and ecosystem institutions, with particular responsibility for
diseases at the animal-human-ecosystem interface; or
• Creating an independent agency for public health, including zoonoses and
food safety, with characteristics similar to those established in Canada and
Denmark. For example, the Canadian Food Protection Agency has delineated
a key priority for the Office of the Chief Food Safety Officer to ‘steward’ One
Health nationally.
11
ONE HEALTH MANUAL
2. Building Strong Relationships and Establishing Trust among the Different

Actors
The effectiveness of relationships in One Health endeavours is a key aspect. As stated
earlier One Health requires a trans-disciplinary approach to be successful. Again, leader-
ship is essential for this way of working to be widely practised and sustained. Currently,
the movement to true trans-disciplinary effort is seen mainly at a research level with this
being one of the key drivers and outcomes of the research programs.
There is a need to cultivate a climate of mutual confidence between the concerned parties,
and between human medicine and health professionals and veterinarians in particular, as
this is a necessary condition for effective collaboration. One way to move towards this is
through education, and assigning importance to joint operations (such as in One Health
teams); this can help to increase opportunities to bridge these professional gaps and to
form interfaces.
Bear in mind that institutional and cultural change is long-term in nature and requires de-
liberate and sustained efforts to achieve.
Legislation that facilitates selective interaction between medical and veterinary services
have to be formulated. With a proper legal framework and appropriate training, however,
certain select public health activities could be shared—for instance, in surveillance by hu-
man and animal health field agents.
Relationships are needed not just among professionals. The community is an integral part
of One Health, being both the informer and the beneficiary. Techniques that maximize
the use of community knowledge, provide additional knowledge, and impart skills, are
needed. Participatory epidemiology using participatory rural appraisal techniques (PRA)
is based on the understanding that the local population usually have of prevailing diseases
and also conditions that might give rise to diseases, and is used in concert with other sur-
veillance methodologies.
Success in One Health also needs cultural and societal values to be an integral part of the
process.
3. Infrastructure
One Health infrastructure has to be developed. It includes:
(a) surveillance and laboratory systems,
(b) networks of expertise,
(c) dedicated services for development of skills and capacity, communication and
information channels and
(d) organizational and policy frameworks to support One Health.
Clearly, Malaysia has much to do in this area.

Most attention to date has been in the development of surveillance and laboratory sys-
tems, and those of expert networks. Monitoring of environmental health occurs separately
to human and animal health activities, and there are very few linkages. This is the area
that remains least well developed in terms of a One Health approach.
12
INTRODUCTION
4. Provide appropriate incentive framework

According to the World Bank, although public health is underfunded in relation to health
care, the human health sector has significantly more human and financial resources avail-
able for disease control activities than have environmental or animal health agencies.
Hence, public health efforts to increase attention to zoonotic diseases often fail because of
the lack of funds from the veterinary and environmental agencies.
Incentive policies that place a premium on collaboration and resource sharing should
therefore be introduced. This can include shared budget lines between different agencies
and systems of matching grants, with increased cooperation leading to increased budget-
ary support. An overall increase in funding would have to be based on the results of the
risk assessment.
5. Communication and technology

The country need to harness the power and the rapid growth and sophistication of new
technologies— particularly information technology—to assist it in many areas underlying
the One Health approach, including communication, data management, pathogen detec-
tion, risk analysis, and modelling.
They include:
(a) Geographic Information Systems (GIS) which enables activities such as herd
mobilization mapping, and research related to mixing of wildlife and livestock,
(b) Smart phones and spreading availability of Wi-Fi which enables collection and
transfer of information easier and faster,
(c) Molecular sciences making available complex sequence data on a single patho-
gen thus leading to the widespread use of molecular epidemiology to map and
understand more closely the spread of viruses both within and between epi-
demics.
All this science can be equally applied to human or animal health and the skills and
knowledge to utilize these technologies have a clear One Health dimension.
6. Improve Disease Surveillance

There is a need to improve the quality of a disease surveillance and control system by
improving the speed with which potential health risks are identified and measures to miti-
gate them are undertaken. Some actions that can be taken include:
a) consultation in priority setting between human and veterinary health agencies;
it is an important area of potential convergence; the risk assessments should
identify hot spots upon which the efforts of surveillance systems can focus,
and in which the monitoring activities of different agencies can converge.
b) joint preparedness planning—among the principal challenges encountered
when preparing the action plans will be the high transaction costs of assem-
bling multidisciplinary teams with members from multiple institutions,
c) Coordinating surveillance services to prevent delays in diagnosing emerging
zoonoses—for example, the West Nile virus in New York City in 1999—as a
13
ONE HEALTH MANUAL
result of the disconnect between public health and veterinary surveillance sys-
tems; this includes coordinating grassroots surveillance systems through the
participation of community representatives, and sharing facilities such as trans-
port and cold storage equipment;
7. Education and Training

This consist of three components, namely:
(a) training in basic traditional outbreak management,
(b) training in thinking and acting across disciplines, and
(c) training in One Health core competencies.
a) Training in basic traditional outbreak management,
Current weak areas where training is needed include:
• Molecular methods of detection of organisms
• Serological method of detection for public health purposes
In addition, there is a need for continuous training of investigation and control teams to
improve
• outbreaks management in general
• investigation skills
• proper use of appropriate PPEs e.g.: donning & doffing
• sampling-taking techniques and sample handling
• Infection control including disinfection
• Data management: handling, analysis, interpretation, etc.
• Report writing
• Risk communication
b) Training in thinking and acting across disciplines
One Health requires thinking and acting across disciplines as a basic tenet. Ideally skills
are ‘trans-disciplinary’ that is, not just to know how other disciplines work but sharing
skills and agreed goals.
One of the ways to demonstrate the necessary skills and benefits is to use examples and
case studies of success stories, such as those described in the ‘One Health for One World:
a Compendium of Case Studies’ assembled by Veterinarians Without Borders. Another
example based on the West Nile outbreak in New York City in 1999 is shown in Appendix
Introduction 3.
Conduct joint training of community health technicians and animal health technicians to
enable trainees to play a critical role in the early detection of emerging zoonotic diseas-
es. Joint training and joint simulation exercises for veterinary officers and health officers
using the Ministry of Health’s Epidemic Intelligence Programme training framework can
also be conducted.
c) Training in One Health Core Competencies

Local universities, the Ministry of Health and Department of Veterinary Services have to
get together to develop a curriculum for training in One Health Core Competencies. For
14
INTRODUCTION
example, One Health Summer Schools are now available in Denmark, England and Aus-
tralia and Masters in One Health are offered in USA and UK, and as a doctorate in the
USA.
One Health core competencies are the unique competencies that all One Health profes-
sionals should have, regardless of their discipline of origin, e.g. “Foster open communi-
cation across disciplines to support and enable a One Health response”. They represent
the confluence of veterinary, human health and environmental core competencies (Figure
Introduction 5).
The current global domains for One Health competencies are:
(a) planning and management,

(b) communication and informatics,
(c) culture and beliefs,
(d) leadership,
(e) collaboration and partnership,
(f) values and ethics, and
(g) systems thinking.
The core competencies and domains for three different proficiency levels are shown in
Appendix Introduction 4.
Figure Introduction 5: Model core competencies for one health

Source: Hueston W, Kunkel R, Nutter F, and Olson D (2014)
15
ONE HEALTH MANUAL
The Way Forward

1. Break down professional silos
While the One Health approach has been greeted widely with enthusiasm, it can also be
argued that it has now reached a cross-road. To go forward, it is essential that professional
silos are broken down to present a common, trans-disciplinary approach to health issues at
the animal–human-ecosystems interfaces, and that the three major international organiza-
tions (WHO, FAO, OIE) together with other international partners must begin to provide
the global leadership which is presently lacking.
2. Secure funding
It is also essential that resources be made available to support research in the One Health
arena, and particularly in developing a better understanding of the human–animal ecosys-
tems interfaces including wildlife and animal disease surveillance. The majority of emerg-
ing diseases arise from animals but the vast majority of funds are spent on understanding
and controlling them in humans.
3. Invest in frameworks, policies and processes

There is an immediate need to invest in the frameworks, policies and processes required
to better identify, articulate and manage risks posed to trade, human health and biodiversi-
ty by diseases with wildlife and animals as part of their ecology.
4. Develop frameworks and standards for research, education and core com-
petencies
Globally accepted frameworks and standards for research, education and accepted core
competencies are required along with the need for an identified career path.
5. Governance
There are two levels of governance: global and local. At the global level, ‘good gover-
nance’ is used to refer to human and animal health systems which comply with interna-
tional regulations, standards and obligations to protect people and livestock against major
health threats that have the potential to spread internationally.
A coherent system of global health governance is the collective defence against transna-
tional health threats and should embody the principles of accountability, transparency,
monitoring and enforcement.
Relating to the human health sector, it focuses mainly on the key functions associated
with the IHR (2005): early detection, proper management and early response to public
health emergencies of international concern (PHEICs). Concerning the animal health sec-
tor, it also centres on early detection, response and control of pathogenic agents to animals
and, in the case of zoonoses, to humans, as outlined in the intergovernmental standards
contained in the OIE Terrestrial Animal Health Code (Terrestrial Code) 2016 and the
Aquatic Animal Health Code (Aquatic Code).
16
INTRODUCTION
At the local level, in cognisance of the fact that around 60% of all human diseases and
around 75% of emerging infectious diseases are zoonotic (transmissible from animals to
humans), good governance corresponds to systematic inter-sectoral collaboration at the
human–animal interface in order to address common challenges as effectively and effi-
ciently as possible.
There is a need to identify a body that can lead relationship development between ma-
jor disciplines and foster a true transdisciplinary approach, develop global guidelines and
strategies, and ensure sustainable funding is needed, probably in an advisory capacity .
We have many more miles to go and lots to do in increasing the awareness and knowl-
edge of One Health paradigm and improving the attitudes towards it and practice before
One Health becomes a reality in Malaysia.
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18
CHAPTER ONE
PREPARATIONS FOR
AN OUTBREAK
INVESTIGATION
Dr Andrew Kiyu, Dr Khebir bin Verasahib,

Dr Rozanah Asmah Abu Samad, Dr Azizah Darus,
Dr Sarah Dadang Abdullah,
Dr Badrul Hisham b Abd Samad
ONE HEALTH MANUAL
1.0 Introduction
Organisations responsible for outbreak management should ensure that they have planned
how they will deal with an outbreak when it occurs—even at inopportune times such as
on weekends, during holidays, or when key personnel are already overburdened with oth-
er projects.
Being ever ready for an outbreak is important so that valuable time is not lost organising
the people and materials necessary to investigate and respond to the outbreak while the
trail is still warm. Bear in mind that the likelihood of identifying the source of an outbreak
and interrupting further disease transmission decreases steadily with every day of delay.
The existing outbreak management protocols (both general as well as disease- or syn-
drome- specific) used by the Ministry of Health as well as the Department of Veterinary
Services would contain the preparations that need to be done before outbreaks occur.
However, for the sake of completeness of this Chapter, the relevant Sections from the
Guidelines for the Investigation and Control of Disease Outbreaks. Porirua: Institute of
Environmental Science & Research Limited (updated 2012) have been adapted and in-
cluded here.
In this manual, the pre-outbreak preparation is presented based on the traditional ap-
proach to outbreak investigation. The ideal one health outbreak investigation based on
One Health paradigm work was discussed in detail in the Introduction.
1.1 Preparations for outbreak investigation

1.1.1 Develop Outbreak Plans
Each organisation responsible for outbreak management should develop and continuously
update an outbreak plan. The objective of the plan is to define roles, resources and respon-
sibilities for outbreak management.
a) Outbreak management plan for human health sector

Outbreak management steps that should be documented in the outbreak plans for the hu-
man health sector are presented in Appendix Introduction 3.
Note that while leadership roles for several components may be delegated, for the health
sector, it is the District Health Officer who has the overall responsibility. Upon receipt of
a possible disease outbreak, the District Health Officer will mobilise the Rapid Assess-
ment Team to the site to investigate and verify whether there is indeed an outbreak.
Once an outbreak has been verified, the District Health Officer needs to do two things:
(a) inform the nearest hospital so that appropriate preparations can be made to re-
ceive the patients, and
(b) despatch a Rapid Response Team to conduct further field investigations, and
implement control measures.
Ideally, in the case of an outbreak of zoonotic disease the District Health Officer will coor-
dinate the movement and activities of the Rapid Assessment Team and the Rapid Response
20
PREPARATIONS FOR AN OUTBREAK INVESTIGATION
Team with the counterparts (Rapid Action Team) from the Veterinary Services Department.
The teams from the Health and Veterinary Services will prepare joint reports, recommen-
dations and prepare a draft of the press release to be forwarded to the national Crisis Pre-
paredness and Response Centre which will check and verify the reports and press release
for the Director-General or Minister of Health to do the release.
b) Outbreak management plan for animal health sector

For the Department of Veterinary Services, the outbreak response organisation and roles
are as follows:
i. Activation of Alert Management Team (AMT)
The Alert Management Team (AMT) is part of the Animal Disease Crisis Man-
agement Committee and is led by the Director of Biosecurity and SPS (Sanitary
and Phytosanitary) Management Division to monitor early warning of notifiable
diseases. Upon receiving the disease report through Animal Disease Information
Centre (ADIC), which is under the purview of the Epidemiology and Surveil-
lance Section, the alert management team will verify the report. This team will
report to the Director General (DG) upon confirmation of diseases and situations
that are considered as animal disease crisis. The DG will issue instructions to the
relevant State Director(s) and at the same time, the Minister of Agriculture will
be updated.
ii. Activation of Animal Disease Crisis Management Centre

The Animal Disease Crisis Management Centre chaired by the Director-General
(DG) of Veterinary Services will decide on technical policies to administer, con-
trol, supervise and evaluate the operations of animal disease crisis at national,
state and district level. In addition, this Committee will:
(a) provide expertise, manpower, equipment, financial and biological items
for efficient crisis management
(b) coordinate public awareness campaign and
(c) advise the Government on the best measures to be taken.
iii. Activation of RAT (Rapid Action Team)
The Rapid Action Team (RAT) investigates and provides early warning on the
threat of diseases. Usually, the team consists of well-trained veterinary officers
comprising epidemiologists, veterinarians, and microbiologists (laboratory per-
sonnel).The Rapid Action Team will collect relevant data during the epidemi-
ological investigation. Important data collected include: species, date of onset,
exposure, mortality, morbidity, address, symptoms of disease, and laboratory re-
sults. Post mortem examination is conducted on the ground during the investiga-
tion. Samples collected are sent to the Veterinary Research Institute (VRI).
The criteria for the activation of the RAT include:

• unusual occurrences of notifiable infectious diseases in the district
21
ONE HEALTH MANUAL
• unusual occurrences of other infectious diseases in the district

• unusual occurrences / clusters of diseases / deaths in the district
• upon directive from a higher authority
The flow chart showing the activities that need to be carried out and the responsibilities of
the animal health and human health sectors is shown in Figure 1.1.
iv. Activation of State Operation Centre
Led by the Director of the State Veterinary Services, this crisis management op-
eration centre at the State level is responsible for administering and controlling
operations in an area or territory specified when there is an animal disease out-
break. Its other scopes and functions include:
(a) ensuring reliable and efficient reporting and information management system,
(b) ensuring that public awareness campaigns are being carried out, and
(c) advising the State Government about the appropriate measures to be taken.
1.1.2 Prepare And Update Outbreak Protocols

The outbreak plan should clearly document or identify locally appropriate protocols for
outbreak management. The outbreak protocols should encompass the entire outbreak man-
agement process. Outbreak protocols should suggest thresholds for each stage of the out-
break investigation and response, including whether investigation should commence at all.
(Note: These outbreak protocols differ from outbreak investigation protocols which de-
scribe standardised processes to follow when collecting and recording information.)
It is important that districts develop and individualise their own protocols so that they are
relevant to local circumstances. Reaching local agreement on suitable threshold levels
for action, and incorporating them into plans, helps avoid doubts about the course to take
when an outbreak does occur.
1.1.3 Identify and Appoint Outbreak Coordinators at State and District Levels
Outbreak coordinators have a key role in outbreak management. They are the liaison be-
tween the District, the State and the Ministry of Health, ensuring the rapid dissemination
of information about emerging outbreaks. The outbreak coordinators also have primary
responsibility for activating outbreak protocols and calling together the outbreak manage-
ment team. During an outbreak itself, the outbreak coordinators are the central point of
contact for the different arms of outbreak management.
1.1.4 Form Outbreak Teams

Each State and District should designate experienced staff who can respond immediately
when an outbreak is recognised. Such staff are trained in outbreak management methods.
They should have permission to suspend their regular duties when the need arises, and
promptly undertake the tasks of initiating outbreak investigation and response.
Who should be in an outbreak team

Outbreak teams usually have two layers - the Core Team and advisors to the Core Team.
In our context, the Core Team would be the Rapid Action Team of the Veterinary Services
22
ANIMAL HEALTH ACTIVITIES COMMON TO BOTH ANIMAL HUMAN HEALTH

RESPONSIBILITIES HEALTH AND HUMAN HEALTH SECTORS RESPONSIBILITIES
District Veterinary Receive / obtain outbreak information from District Medical Officer
Officer/ADIC various sources of Health
• Media
• Community
• District/State/National Surveillance
activity
• Farmer/Animal Owner
AMT to verify the report
Mobilise RAT
National RAT Verify the outbreak District Medical Officer

of Health
(Rapid Action Team) Outbreak (Rapid Assessment Team)
No
National RAT District RAT
Yes
(Assessment and
Investigation)
End
Joint Field investigation District RRT

Control measures Infrom
state and national levels
Teams Prepare report and

Laboratory Confirmation Deploy
deployment
teams to theto joint press
(VRI) the outbreak statement on disease District RRT
outbreak area.
area. information,
disease control activities,
recommendation,
Disease Control and
Eradication Conduct joint public
awareness programme
(Surveillance, culling, about the outbreak District RRT
stamping out,
decontamination /
disinfection, quarantine,
movement control,
resolve, disease freedom)
Figure 1.1. The activities that need to be carried out and the responsibilities of the animal
health and human health sectors
23
ONE HEALTH MANUAL
Department, and the Rapid Assessment Team and the Rapid Response Team of the State
Health Departments and District Health Offices. For ease of reference, they will be collec-
tively called the Core Team in this Chapter.
The Core Team is responsible for planning, co-ordinating and carrying out the outbreak
investigation. In most circumstances, members of the Core Team will need to be able to
make the outbreak their highest priority, at least in the initial phase. Advisors to the Core
Team are individuals who can be called upon to provide advice about specific aspects, but
normally not to do the legwork required. However, the boundary between the core and the
advisory teams is fluid, and during larger outbreaks advisory team members may be re-
quired to have considerably more hands-on involvement than during small-scale outbreaks.
The composition of the outbreak team cannot be defined rigidly - requirements will vary
depending on the size of the outbreak, the type of outbreak and the distribution of skills
within the organisation.
The outbreak plan should, however, describe who within the organisation (i.e., Ministry
of Health and State Health Departments, and the Veterinary Services Department) has the
requisite skills to be part of the core outbreak team, and should also identify a range of in-
dividuals who can be contacted to provide further advice if necessary.
Try and get the appropriate mix of skills and a multidisciplinary composition in the Core
Team.
The core outbreak team will usually require the following skills related to disease out-
break management (in addition to their specific technical and discipline skills):
• outbreak management coordination and relationship management
• administrative and secretarial
• environmental investigation
• statistical analysis
• questionnaire development
• data entry
• interviewer selection and training
• media and public communication
• knowledge of relevant legislation and regulations
• statutory authority to implement legislation and regulations.
During the outbreak itself, some of the following skills may need to be brought into the
core outbreak teams of the human health and animal health sectors.
Skills common to both sectors:
• cultural competency, in particular for responding to outbreaks among the Indigenous
natives, and migrants
• skills in non-Malay and non-English languages (i.e., translation services specific
to health information)
• microbiology
• laboratory science
• environmental science (soil, water, air)
• virology
24
• additional media and public communication expertise

• workplace health and safety / infection control and prevention
• industry specialists
Skills required by human health sector:

• public health nursing
• clinical medicine
• public health engineering
• food chemistry
• advanced epidemiology
Skills required by animal health sector:

• veterinary epidemiology
Terms of reference for the outbreak team
The terms of reference of the outbreak teams from the human health and animal health
sectors should be agreed upon in advance, as much as possible, and be included in out-
break plans.
An example is shown in a table on the next page.
1.1.5 Assemble materials required for an investigation

Outbreak plan development provides an opportunity to list the materials that may be re-
quired at short notice during an actual outbreak, and to identify where these materials are
kept.
Materials may include:

1. basic stationeries
2. hand-held calculator(s)
3. an outbreak kit containing, among other things: sampling kits, documentation
and materials for collecting and transporting laboratory specimens, etc.
4. appropriate personal protective equipment (e.g., face mask) for use of affected
client (suspected case or farmers)
5. post-mortem examination kit for animal carcasses (for Veterinary RAT)
6. a camera
7. reference books or databases on communicable diseases and toxic substances
8. a computer installed with a basic statistical package (probably EpiInfo and Ep-
iData), packages for word processing and graph preparation, and (preferably)
e-mail capability
9. sample questionnaires from previous outbreak investigations or studies
10. a list of telephone numbers of potentially useful agencies and individuals
11. communication equipment (eg. a smart phone provided by the office)
12. personal identification documents, particularly those providing evidence of stat-
utory designations that may be required during the investigation or management
of an outbreak.
25
ONE HEALTH MANUAL
An example of the terms of reference for the outbreak team:
ACTIVITIES TO BE DONE BY TO BE DONE BY

HUMAN HEALTH ANIMAL HEALTH
SECTOR SECTOR
1. Review the evidence and confirm the exis-
tence or not of an outbreak
2. Develop a strategy to investigate and con-
trol the outbreak and assign responsibilities
for taking action
3. Arrange for the necessary interviews and
other investigations to identify the illness and
contributing risk factors
4. Prevent further cases by taking all nec-
essary and possible steps to ensure that the
source of the outbreak is controlled or the
cause is removed
5. Prevent cases elsewhere by communicat-
ing findings to other agencies and the public
6. Prevent secondary spread of infections by
controlling or isolating cases, and by identi-
fying and managing contacts appropriately
7. Provide an accurate and responsible source
of information for other professionals, the
media and the public
8. Develop systems and procedures to pre-
vent the future occurrence of similar episodes
9. Document the investigation and control
measures.
10. Disease surveillance for staff (of both
sectors) involved in outbreak investigation
and control
11. Disease surveillance and sampling taking
from animals and farm environment
12. Prepare and carry out risk communication
activities
13. Taking samples from humans and the
environment (e.g. soil, water, surfaces)
26
1.1.5.1 Identify resources required for an investigation

The resources required will include the usual four M’s - and more:
• Manpower: human capital and their expertise, including Hazardous Materials
(HAZMAT) Unit of the Fire and Rescue Department.
• Money: financial capital; small outbreaks may be controlled using existing oper-
ating funds of the Department or the Ministries, while major outbreaks many need
emergency funds from Federal level.
• Materials: vaccines, personal protective equipment, health education materials, PCR
primers for labs, outbreak Investigation field kits, mobile labs, etc.
• Methods: outbreak management protocols and outbreak investigation protocols
• Logistics: Transport (Special trucks (4X4); special boats for outbreaks occurring in
islands; Communication (satellite telephones)
Prepare inventory lists of:
• Resources available in the Ministry of Health / Department of Veterinary Services
/ Universities / others/ and labs (including private labs).
• Personal details of staff involved in the outbreak management, such as telephone
nos, home addresses and areas of expertise.
• Laboratories and their capabilities in terms of detecting zoonoses - existing as well
as emerging infectious diseases
1.1.5.2 Where to seek help and resources
For technical components, help and resources can be sought from the following:
• Within state / country / region / international
• Between sectors—health / veterinary / Universities / Hazardous Materials
(HAZMAT) Unit of the Fire and Rescue Department.
• International—WHO, OIE, FAO, CDC (US)
• AAHL (Australian Animal Health Lab), Geelong, Australia
• Reference Labs for various diseases and organisms
For the Control component, help may be sought from the following;
• Community leaders to help in community awareness, mobilisation and participation
• Law enforcement agencies (to investigate the deliberate release of microorganisms)
• Legal authorities
• Countries of origin of imported diseases (country focal points)
1.2 Preparations for Outbreak Investigation Based on One Health Paradigm
There is a paucity of information in literature regarding the specific preparations for out-
break investigation based on the One Health paradigm. Almost all relevant scholarly ar-
ticles and books agree on the need for a robust preparation for outbreak investigation as
outlined above, but how this should be done differently in the One Health approach, re-
mains unclear at the moment.
Nonetheless, among the preparations that need to be carried out include the following:
i. Investigation: Adequate scientific knowledge of the epidemiology of the particu-
lar zoonotic infection on hand is needed and necessary supplies and equipment are
collected (as listed above). If needed, for example where the outbreak concerns an
27
ONE HEALTH MANUAL
emerging disease or a disease on which knowledge is limited, local and internation-

al experts and resources may have to be called in or consulted.
ii. Administration: Administrative procedures, such as approval for travel plans and
budgets are obtained. Since One Health approach to the investigation of zoonotic
disease outbreaks involves experts from a variety of disciplines, collective approval
from the leadership ministry and/or its head is most desirable. Where this is struc-
turally not available, it is important to commence the approval process from the re-
spective ministries immediately upon receiving a notification.
iii. Consultation: Immediate contacts with members of the One Health outbreak re-
sponse/coordination team should be established. This includes addresses and phone
numbers and details of meeting schedules. A clear description of the roles and re-
sponsibilities of every team member should be clarified and agreed. Clear reporting
and communication lines should also be established and agreed between the nation-
al, state departments and district health offices.
iv. Joint visits to affected areas: Ideally and whenever possible, the human health and
animal health sector teams should make joint visits to the affected areas so that the
farmers and people affected will not be repeatedly interviewed by different teams
which may lead to “respondent fatigue”. Furthermore, joint interviews will enhance
the quality of the data gathering process.
BIBLIOGRAPHY
MOH 2006. National Influenza Pandemic Preparedness Plan. Putrajaya, Malaysia: Min-
istry of Health Malaysia.
OIE 2013. Aquatic Animal Health Code [Online]. World Organization for Animal Health.
Available: http://www.oie.int/en/international-standard-setting/aquatic-code/ [Accessed
August 23 2016].
OIE 2016. Terrestrial Animal Health Code. [Online]. World Organization for Animal
Health. Available: http://www.oie.int/en/international-standard-setting/terrestrial-code/
[Accessed August 23 2016].
RASHID, A. K., AND NARAYAN, K.A. 2010. Lecture Notes on Epidemiology 2ed.
WHO 2006. Strategic action plan for pandemic influenza. Geneva: World Health Orga-
nization.
28
CHAPTER TWO
ESTABLISH AND VERIFY

DIAGNOSIS
(DEVELOPING CASE DEFINITIONS AND
DESCRIPTIVE EPIDEMIOLOGY TO
ESTABLISH OUTBREAK)
Dr John T Arokiasamy, Dr Rosnah Ismail, Dr Seng Fong Lau,

Dr Ahmad Filza Ismail, Dr Nurul Syuhada bt Zainal Abidin
ONE HEALTH MANUAL
2.0 Introduction
The aims of this chapter are to:
(a) establish and verify diagnosis of zoonotic disease based on the history taking,
clinical examinations and laboratory findings.
(b) develop a clear case definition which allows standardization of the cases of
interest both within an ongoing outbreak investigation and possibly between
outbreak investigations that differ over time or geographic locations.
(c) develop a method of descriptive epidemiology in a way that the data organiz-
ing and analysing would make better understanding of disease variations over
time, place and personal characteristics.
2.1 Common Epidemiological Terms in Handling Zoonotic Disease

Agent: A factor, e.g. a microorganism, chemical substance or radiation, the presence or
excessive presence of which is essential for the occurrence of disease.
Carrier: A person or animal without apparent disease who is capable of transmitting the
agent to others. Carriers may be asymptomatic, i.e. who never show symptoms during the
time they are infected. Incubatory or convalescent carriers are capable of transmission be-
fore or after they are clinically ill.
Chronic carrier: A person who harbours an agent for an extended time following the ini-
tial infection. Chronic carrier in animals may not exist because once the infectious antigen
is detected, the animal will be culled at slaughter houses.
Contact: A person or animal that has been in an association with an infected person or an-
imal or a contaminated environment in such a way that provides an opportunity to acquire
the infection.
Contamination: The presence of a disease agent on a body surface, in clothes, bedding,
toys or other inanimate articles or substances, including water and food.
Generation time: The period between the receipt of infection by the host and the maximal
communicability of the host.
Herd immunity: The resistance of a community to a disease. It is not necessary to achieve
100 percent immunity in a population in order to halt an epidemic or control a disease.
Host: Human or animal that harbours the infectious agent and able to transmit the disease.
Immunogenicity: The ability to produce specific immunity, primarily humoral, cellular
immunity, or a mixture of both in the host.
Incubation period: The time interval between the receipt of infection and the onset of illness.
Index case: The first case in a family or other defined group to come to the attention of
the investigator.
Infection: when an infectious agent has entered and established itself in a host.
Infectivity: The ability of an agent to invade and multiply in a host.
Pathogenicity: The ability of an agent of infection to produce disease.
Primary case: The individual who introduces the disease into the group under study.
Reservoir: An animal that harbours the infectious agent which is able to multiply itself,
with or without any clinical signs.
30
ESTABLISH AND VERIFY DIAGNOSIS
Secondary case: The case of disease occurring among contacts within the incubation pe-
riod, following exposure to the primary case.
Susceptible host: A person or animal not possessing sufficient resistance against a par-
ticular pathogenic agent to prevent contracting infection or disease when exposed to the
agent.
Suspect: A person whose history and symptoms suggest that he or she may have or may
be developing a communicable disease. A suspect in animal is an animal with clinical sign
and history of contact with the infected herd.
Virulence: The ability of the pathogen to multiply within the host. Virulence may depend
on dose, route of infection and host factors such as age or race.
Zoonotic disease: An infection or infectious disease transmissible under natural condi-
tions from vertebrate animals to humans.
2.2 Establish and Verify Diagnosis of Zoonotic Diseases
2.2.1 Data Sources of Establishing Zoonotic Disease
a) National surveillance mechanism – laboratory-based surveillance (both
for human health and veterinary), mandatory notification disease sur-
veillance, clinical-based surveillance (sentinel/ national/ syndromic ap-
proach), community based surveillance (community, media and inter-
national), animals surveillance system by DVS and other agencies such
as Fomema Sdn Bhd. Clinical-based surveillance include acute flaccid
paralysis, acute gastroenteritis, acute jaundice syndrome, acute neuro-
logical syndrome, acute respiratory syndrome, acute dermatological syn-
drome and acute haemorrhagic fever syndrome.
(b) Active and passive surveillance.

i. Human
Human active surveillance includes active case detection and case being
investigated or case-based record. The surveillance aims to obtain infor-
mation pertaining to:
• Socio-demographic - age, sex, geographical information, occupation
• Clinical symptoms - determine if anybody else has similar signs/symptoms
or characteristics (family members, acquaintances, workers,)
• Hospitalization event - date of onset, date of diagnosis; microbiological
and serological data
• History of exposure to animal contact (e.g. pets, work with animals), dis-
turbed environment (e.g. flood, deforestation and recreational activity),
travel and trade activities
Human passive surveillance captures regular reporting of disease data by

all institutions that see patients (or test specimens). There is no active
search for cases. It involves passive notification by surveillance sites and
reports are generated and sent by local staff.
31
ONE HEALTH MANUAL
ii. Animal
Animal active surveillance which includes, disease index and surveil-
lance during outbreak are done for diseases that are economically im-
portant. These include field observation in the designated premises such
as milk industry, livestock production and breeding premises, slaughter-
house and processing plant.
The field observation should be on clinical signs, high morbidity and

mortality of animal and must be reported. Suspected samples from these
premises must be sent to the nearby regional veterinary laboratory and
the results must be submitted to Animal Disease Information Centre
(ADIC).
Animal passive surveillance includes monitoring activities from general

public, media, Internet and recognized agencies such as OIE, WHO, Min-
istry of Health Malaysia, Wildlife Department and Fisheries Department.
c) Early warning response system related to infectious disease – environ-

mental changes (e.g. meteorological parameters)
2.2.2 Verify Diagnosis of Zoonotic Diseases

Verifying that the zoonotic disease is occurring is closely linked to confirmation of the ex-
istence of an outbreak itself. Goals in verifying the diagnosis are to:
(a) ensure that the problem has been accurately diagnosed,
(b) rule out laboratory error or changes in laboratory practice or changes in diag-
nostic (i.e. availability of new test) or reporting procedure as the basis for the
increase in diagnosed cases, and
(c) rule out changes in clinical practice, as these can artificially increase the num-
ber of diagnosis.
An increased number of confirmed true cases in the actual number of cases of disease
may not represent an outbreak either, since there are other potential explanations for true
increases in disease occurrence, such as increase in population size, changes in population
characteristics, increase in the rate of illness due to random variation (fluctuation) in inci-
dence or increase in the rate of illness due to an increase in risk behaviours.
In order to verify whether the increase in the number of cases is artificial or genuine, the
following steps are essential:
» determine if a change in the total number of specimens submitted for testing
might have artificially increased the number of cases.
» determine whether there has been a change in the proportion of specimens that
test positive.
» determine whether there has been a change in the method(s) used for laboratory
testing, a change in laboratory policy or personnel or laboratory reporting.
» determine whether other nearby laboratories have seen similar increases.
32
2.3 Develop a Human Case Definition in an Outbreak Investigation

A case definition is the standard criteria for categorizing an individual as a case. However,
the case definition should not be used as a basis for clinical diagnosis, treatment or other
management of individuals. The case definition may be repeatedly revised later as new
information is obtained in the outbreak investigation.
The primary objective in developing a case definition is to include as many individuals as

possible who are likely to be part of the outbreak (sensitivity), while excluding as many as
possible who are not likely to be part of the outbreak (specificity). In the earliest stages, it
might be broader and less specific in order to make sure the case definition identifies all
of the suspected cases, but later on, it might include more specific clinical or laboratory
criteria that will enable the investigator to categorize individuals as “probable” or “con-
firmed” cases. As a result, the case definition may change during the investigation.
The case definition should be developed by reviewing details of cases reported to date
based on the following:
(a) A definition of the health events to be counted. This definition usually consists of
clinical and laboratory features. Clinical features include precise, shared character-
istic signs and symptoms of the disease and details of the cases pertaining to time
(period during which the diagnosis occurred), place (geographical area) and, some-
times, persons (population group of interest). Cases can be identified as common
event (e.g. attended same party), dispersed (e.g. outbreak associated strain of Sal-
monella Montevideo isolated from a stool sample collected during an earlier date),
common site (e.g. a person domiciled in the health district and notified to Health
State Office), person to person (community) or institutional (nursing home, hostel
and camping base). In an ideal situation, all cases require laboratory test results
confirming the presence of a pathogen or toxin-causing disease.
(b) The human case definition must not include exposure characteristics that relate
to the possible outbreak source. For example, the details of the suspected exposure
causing the cases of disease (e.g., consumption of a particular food or water from
a particular source) may lead to difficulty in interpreting statistical relationship be-
tween exposure and disease under investigations.
2.3.1 Establishing a human case definition:

a) The initial case definition steps
The process for writing a refined case definition includes:
i. Identifying clinical presentation (sign and symptoms), laboratory results, and

epidemiologic information available (place of event, time from the event
and exposure history) regarding reported cases
ii. Formulating initial case definition
At the earliest point in an investigation, the definition will be based initially
on the major clinical characteristics of the reported persons. When a specif-
ic diagnosis has been made or an agent has been identified, then the initial
33
ONE HEALTH MANUAL
definition of a case should include relevant laboratory criteria. The defini-

tion should also include epidemiologic criteria if risk factors relevant to ex-
posure are evident upon initiation of the study.
b) The refined case definition steps

The process for writing a refined case definition includes:
i. Identifying the laboratory tests which confirm or support a diagnosis of the

disease
ii. Identifying the signs and symptoms which cases of this disease might have.
List separately, if possible, those which are invariably present and those
which may or may not be present in any given case.
iii. Identifying the actual time of onset and exposure histories of the cases.
iv. Specifying the case categories to be defined for the purposes of the investi-
gation
v. For each category, writing down the combination of laboratory, clinical, and
epidemiologic characteristics which are to be used to define each.
c) Contents of a case definition:

A human case definition includes criteria for person, place, time (also known as
the epidemiological variables) and clinical features (specific to the outbreak un-
der investigation).
“Person” describes key characteristics the patients share in common. For exam-
ple, this description may include: age, sex, race, occupation and exclusion crite-
ria (e.g., “persons with no history of ‘X’ disease”).
“Place” typically describes a specific geographic location (state, county) or facil-

ity associated with the outbreak (‘X’ nursing home, ‘Y’ high school, working in
‘Z’ company). Most easily assessable by examining line listing.
“Time” is used to delineate a period of time associated with illness onset for the
cases under investigation. It depends on the usual occurrence of the disease and
the incubation period of the aetiological agent. Limiting the time period enables
exclusion of similar illnesses which are unrelated to the outbreak of interest.
This is best determined by drawing an epidemic curve.
“Clinical features” should be simple and objective (e.g., sudden onset of fever
and cough). The clinical criteria may later be characterized by the presence of
specific laboratory findings
34
Examples:
Person
» Age group: “Age of 5 to 10 years”
» Sex: “Male”
» Occupation: “Health care workers at hospital ‘X ’
» Exclusion criteria: “Persons with no previous history of chronic
cough or asthma”
» Race
Place
» Geographic location: “Resident of ‘Y’ state”, latitude and longitude
coordinates
» Facility: “Transit in ‘X’ kindergarten”; “student at ‘A’ primary
school”
» Time
» Illness onset: “Onset of illness between February 27 and March 10,
2016”
Clinical features
» “fever, abdominal cramp and diarrhoea”
» “clinical or radiographically confirmed pneumonia”
Case definitions are often further categorized by the degree of certainty regarding the di-
agnosis as “suspect”, “probable”, or “confirmed”.
2.3.2 Laboratory Diagnosis
a) Probable diagnosis:
Positive screening test e.g. rapid screening test such as IgM ELISA, latex agglutination
test, urine dipstick etc.
b) Confirmatory diagnosis:
i. Isolation pathogens from blood or other clinical materials through culture
ii. A positive PCR result using a validated method (primarily for blood and se-
rum in the early stages of infection).
iii. Fourfold or greater rise in titre or seroconversion in microscopic agglutina-
tion test (MAT) on paired samples obtained at least 2 weeks apart.
2.4 Develop Human Exposure Classification

Human exposure should be based on history of close contact (direct or indirect) with res-
ervoirs, animals and environmental exposure. The human exposure is further classified as
follows:
Possible exposure: A person who had close contact (direct or indirect) with reservoirs
animals in endemic area.
35
ONE HEALTH MANUAL
Probable exposure: Possible exposure plus an animal displaying clinical signs consistent
with disease under the investigation at time of the exposure, or within incubation period
following exposure in endemic area.
Exposed: Probable exposure with laboratory-confirmed diseased animal and/or positive
tested environmental sampling (water and soil).
Example:
A 35-year-old man presented to Hospital Serdang at 1 am with the complaint of fever for
five days after returning from a holiday in Jeram Toi waterfall. He had myalgia, nausea,
vomiting and diarrhoea. During the physical examination, the patient had a blood pres-
sure of 120/70 mm Hg, a heart rate of 120 beats/min, a respiratory rate of 16 breaths/
min, and a temperature of 39.4°C. Oxygen saturation was 95%. There was no evidence
of jaundice and both sclera showed peripheral vascular injection. Laboratory examina-
tion revealed a white blood cell (WBC) count of 16,400 cells/mm3 (normal range 4,000–
10,000 cells/ mm3), a haemoglobin level of 15 g/dl (12–17 g/dl), a platelet count of
189,000 cells/mm3 (150,000 – 450,000 cells/mm3), an aspartate amino-transferase (AST)
level of 245 U/L (N<40), an alanine aminotransferase (ALT) level of 198 U/L (N<45),
creatinine kinase 5,420 U/L (N<190), and creatinine 174 µmol/L (N 70-110). Urinaly-
sis showed some erythrocytes, leukocytes, granular cast and a strong reaction for protein
and hemoglobin, which indicated rhabdomyolysis. Leptospira IgM ELISA was positive on
day one with a titre of 1:160 and increased more than ten-fold (1:5,120) in day 14. The
microscopic agglutination test (MAT) was strongly positive for Leptospira interrogans se-
rogroup Icterohaemorrhagiae.
Classification of human case:

Suspected: The case is compatible with the clinical case definition to the known or report-
able disease/conditions i.e. fever, myalgia, nausea, vomiting and diarrhoea.
Laboratory: May not be needed.
Probable: The suspected case plus history of contact with a suspected reservoirs animal
and/or positive screening test.
Confirmed: The probable case plus positive confirmatory laboratory test.
Therefore, the final human case definition is:
A case presenting with fever, myalgia, nausea, vomiting and diarrhoea with positive Lep-
tospira IgM ELISA and positive miscroscopic agglutination test (MAT) for Leptospira in-
terrogans serogroup Icterohaemorrhagiae.
Classification of human exposure to Leptospira agent:

Possible exposure: A person who had close contact (direct or indirect) with reservoirs in
the endemic area (i.e. Jeram Toi waterfall).
2.5 Descriptive Epidemiology

Descriptive epidemiology focuses on “person, place, and time”, i.e., the personal charac-
teristics of the cases, changes in disease frequency over time, and differences in disease
frequency based on location. Characteristics of person, place, and time are the essential
36
elements of both descriptive epidemiology (to identify possible sources) and for analytic
epidemiology (to definitively identify the source).
2.5.1 Collecting and recording data

As cases are identified, it is important to record information in a systematic way
and to organize it in a way that will make analysis much easier, such as creating
a line listing. Line listing can be created on paper (hardcopy) or on a computer
using Microsoft Excel or freeware such as EpiInfo (http://www.cdc.gov/epiinfo/
index.html) and Epidata (http://www.epidata.dk) All line listings should include
the components of the case definition (clinical descriptions and laboratory crite-
ria for diagnosis) including variable of interest such as gender, age, occupations
and relevant exposures (Table 2.1).
Table 2.1. Example of line listing for Leptospirosis
Signs/Symptoms Laboratory Demographic
Case# Report Date Onset Physician Diagnosis
My N V D F J LeptolgM Other Sex Age
1 12/10/2015 05/10/2015 Leptospirosis 1 1 1 1 1 1 1 MAT +ve M 37
4 13/10/2015 09/10/2015 NA 0 0 0 ? 1 0 NA NA F 44
5 15/10/2015 Leptospirosis 1 1 1 1 1 0 1 MAT +ve M 17
6 16/10/2015 06/10/2015 Leptospirosis 0 0 0 1 1 1 1 MAT +ve F 43
My= myalgia, N= nausea, V= vomiting, D= diarrhoea, F= fever, J= jaundice, LeptoI-

gM = Leptospira IgM ELISA, MAT= microscopic agglutination test
1= Yes, 0= No
2.5.2 What information should be collected?

The following information should be collected from cases:
a) Personal information: name, address, phone number, age, sex, race and occupa-
tion.
b) Signs and symptoms, as appropriate, for the type of outbreak under investi-
gation in confirming the diagnosis and determining that the subject meets the
case definition.
c) Relevant history of exposures:
» Exposure to reservoirs animals and contaminated environments (wa-
ter and soil)
» Occupational exposure while doing routine job activity
» Exposure to contaminated water and food, especially ready to eat
d) Laboratory Test Results: screening and confirmatory
e) Other information e.g. food handling activities
2.5.3 Aggregated data reporting:

• Number of suspected and confirmed cases
• Number of hospitalizations
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ONE HEALTH MANUAL
• Number of deaths (both human and animals)

• Number of cases by type (causative serovarians/serogroup) of pathogens
for human and animals.
2.5.4 Epidemiological Descriptive Analysis

Descriptive analysis is crucial to identify the hypotheses about the source of outbreak and
identify the ways to control the outbreak. Descriptive analysis is important to characterize
the cases in terms of person, place and time.
a) Counting cases
i. Prevalence
Prevalence is an estimate of the proportion of individuals in the population with a
given disease, disability or health state at a particular point in time. It is also the
measure of the existence of a particular condition, i.e. prevalence measures the prob-
ability of people having a disease at a given point in time. Prevalence is not strictly a
rate although it is sometimes referred to as one. It is a proportion and should usually
be reported as such. The major difference between incidence and prevalence is that
knowledge of time of onset is not required in a prevalence study. Denominators in
prevalence rates always include the entire population since the numerator contains
old as well as new cases.
Prevalence depends on two factors: the number of people who have been ill in the past
(previous incidence) and the duration of their illness, P ~ I x D; if incidence and dura-
tion have been stable over a long period of time then this formula becomes P = I x D.
ii. Incidence
Incidence measures the number of new cases or new events of disease which de-
velop in a given population during a specified time period. Incidence rates mea-
sure the probability that healthy people will develop a disease during a specified
period of time.
Cumulative incidence is the proportion of people in a total population at risk but

free of disease at the start of a particular time period who become diseased or
develop the incident condition during the specified time period. Cumulative in-
cidence provides an estimate of the probability (or risk) that an individual will
become diseased in the specified time period.
Incidence Rate is a true rate and is considered to be an instantaneous rate of de-

velopment of disease in a population. The numerator is the number of new cases
or incident cases in the population.
iii. Attack Rate
It is a variant of an incidence rate. When the study period spans the entire epi-
demic, the term attack rate is used to describe infectious disease outbreaks e.g.
outbreaks of zoonotic infections. The attack rate is useful for pinpointing suspect
causative agents.
38
iv. Secondary Attack Rate

This is a measure of the frequency of new cases of a disease among the contacts
of known cases. To calculate the total number of household contacts, we subtract
the number of primary cases from the total number of people residing in those
households. It indicates the infectivity of the organism.
b) Epidemic Curve
Epidemic curve depicts the time course of the onset of symptoms among cases in an out-
break. Epidemic curve is useful to illustrate the dynamics of the outbreak i.e. number of
new people affected over time, distribution of cases over time, outliers, most likely time
of exposure, general sense of the outbreak’s magnitude and its pattern of spread. By ob-
serving the curve, the mode of transmission and the incubation period can also be ascer-
tained. Moreover, the adequacy and control measures effectiveness in reducing the inci-
dence of the disease can be determined.
The epidemic curve has the following format:
• the x-axis depicts the time or date of onset of symptoms. Choose an x-axis scale
based on the period covered by the outbreak and the incubation period of the disease
(if known). Label the timing of key events.
• the y-axis depicts the number of cases. The scale of the y-axis will depend on the
number of cases involved in the outbreak. It may be helpful to denote cases oc-
curring in different subgroups (e.g., different age groups) using different coloured
bars or lines.
The different types of epidemic curves include point source, continuous common source
and propagated outbreak (as shown below in Figures 2.1 to 2.3).
Number of Cases
10
1 5 10 15 20 25 30
Onset Illness
Figure 2.1 Point source outbreak
Source: US CDC
39
ONE HEALTH MANUAL
Number of Cases
10
15 17 19 21 23 25 27 29 31 2 4 6 8 10 12 14 16 18 20
Onset Illness
Figure 2.2 Continuous common source outbreaks
Source: US CDC
26
24
22
20
18
16
14
12
10
8
6
4
2
15 22 29 5 12 19 26 3 10 17 24 31 7 14
OCT NOV DEC JAN
Figure 2.3 Propagated outbreaks
Source: US CDC
c) Strategies for case-finding

1. Below are the strategies for case-finding: Locate a list of individuals who attend-
ed the event associated with the outbreak
2. If list is unavailable, try to obtain a verbal list of names with contact details. If
40
it is still unfeasible, interview the identified cases for names of other individuals
who attended the event
3. Interview family contacts of cases
4. Review notifiable disease reports
5. Request hospitals and general practitioners to report (retrospectively or prospec-
tively) patients who meet the case definition
6. Request laboratories to report if an aetiological agent has been isolated
7. If necessary, advertise in the mass media, requesting the public who have been
to high-risk countries to come forward to be screened
2.6 Establishing an outbreak

An outbreak is an increase in the frequency of a disease above what is expected in a given
population. However, for some diseases such as rabies, brucellosis and avian influenza,
even a single case of zoonotic disease in human is considered as an outbreak.
Most local health departments are more likely to investigate an apparent outbreak when the
number of affected (or exposed) persons is large, when the disease is severe (serious illness with
high risk of hospitalization, complications, or death), when effective control measures exist, and
when the outbreak has the potential to affect others unless prompt control measures are taken.
For reportable diseases, baseline rates of disease (i.e., the usual or expected rate) can
be determined from surveillance data, and compare rates during the previous month or
weeks with the current rates of disease.
For non-reportable diseases or conditions, baseline data can be obtained from state or na-
tional vital statistics, from disease registries, or from hospital discharge records. The data
can be displayed by the number of cases of disease over time graphically to create an epi-
demic curve. The epidemic curve provides clues about the source of the infectious disease
outbreak.
Note: Be aware that apparent changes in disease frequency can result from
- Changes in case definitions or changes in local reporting procedures
- Increased interest in a disease because of local or national awareness might result in

greater scrutiny by health care workers or more frequent requests from patients for exams
and diagnostic procedures
- Improvements or changes in diagnostic or screening procedures (e.g. introduction of the

prostate-specific antigen test for prostate cancer resulted in an apparent increase in the fre-
quency of prostate cancer)
- Sudden changes in the size or composition of the population (e.g., students returning to
school in the fall or an influx of migrant workers)
41
ONE HEALTH MANUAL
Where to seek for help and resources
WHAT WHOM WHERE

Case definition Epidemiologist Health District Office
- Suspected State Health Department
Surveillance Officer
- Probable DVS
- Confirmed
Human cases Public Health Physician Health District Office
- Outbreak investigation
and control
- Vaccination
Animal cases Veterinary Public DVS
- Outbreak investigation Health
and control
- Vaccination
Human sample handling and Microbiologist Public Health Laboratory
Laboratory confirmation
Regional Veterinary
Laboratory
Hospital Laboratory
University and Institute
Laboratory
Animal sample handling and Veterinary Microbiol- Regional Veterinary
Laboratory confirmation ogist Laboratory
VRI
Human cases Family Medicine Spe- Health Clinic
- Management cialist
Hospital
Emergency Medicine
Specialist
Infectious Disease Phy-
sician
42
BIBLIOGRAPHY
CDC 2016. Using Epi curve to determine mode of spread. [Online]. Atlanta, USA:
US Centers for Disease Control and Prevention. Available: http://www.cdc.gov/training/
quicklearns/epimode/ [Accessed August 23 2016].
ESR 2012. Guidelines for the Investigation and Control of Disease Outbreaks. Porirua:
Institute of Environmental Sciences & Research Limited.
TOROK, M. 2014. FOCUS on Field Epidemiology Case Finding and Line Listing:
A Guide for Investigators. [Online]. North Carolina, USA: North Carolina Center for
Public Health Preparedness - The North Carolina Institute for Public Health. Available:
http://sph.unc.edu/nciph/focus/ [Accessed August 23 2016].
WAGENAAR, J. F., VRIES, P.J. AND RUDY HARTSKEERL, A., 2004. Leptospirosis
with pulmonary hemorrhage, caused by a new strain of serovar Lai: Langkawi. Journal
of travel medicine, 11(6), 379-382.
43
CHAPTER THREE
LABORATORY
INVOLVEMENT
Dr Ramlan Mohamed, Dr Fairuz Amran, Associate
Professor Dr Rukman Awang Hamat, Associate Professor
Dr Syafinaz Amin Nordin, Associate Professor
Dr Ariza Adnan, Dr Zurin Azlin bt Md. Jinin,
Dr Taznim Begam bt Mohd Mohidin
ONE HEALTH MANUAL
3.0 Introduction
The laboratory diagnosis is an essential element of communicable disease surveillance,
both for routine confirmation of infections and for the rapid identification of the causes of
outbreaks and epidemics.
The laboratory is involved in laboratory-based surveillance for humans, animals and the
environment. The laboratory-based data are often instrumental in providing early warning
signals and identifying/detecting outbreaks. By using laboratory-confirmed surveillance
information, health workers can make evidence-based decisions for case management and
treatment as well as disease prevention and control.
During an outbreak, the functions of the laboratory in the identification of the causative
agent is an important role in the outbreak investigation. This is particularly for identify-
ing or confirming links between suspected organisms or substances in human or animal
illnesses. Developments in laboratory techniques help improve the sensitivity of outbreak
detection by identifying cases with a common source. Such findings may help strengthen
links between outbreaks and their sources.
The role of the laboratory is also crucial in outbreak preparedness and disease monitoring.
During and in-between outbreaks, the laboratory identifies pathogens and develops labo-
ratory tests and immunization strategies (for new and emerging pathogens). The laborato-
ry aids in disease trend monitoring. The laboratory confirms a diagnosis/case definitions
which include laboratory criteria, monitor resistance patterns and subtypes of a pathogen.
The laboratory also evaluates interventions, monitors progress towards a control objective
and is involved in prevalence studies.
This chapter focuses on the roles of the laboratory upon a disease outbreak alert. Empha-
sis will be on the interface between laboratory investigation and field outbreak investiga-
tion personnel. The objective of this chapter is to increase the knowledge of One Health
Workforce (OHW) and future OHW on the principle roles of laboratory investigation in
handling disease outbreaks.
3.1 Role of Laboratory in Disease Outbreak Investigations

The role of the laboratory in disease outbreak investigations include:
» Ensuring appropriate specimens are collected.
» Arranging appropriate laboratory investigations of the specimen to identify the
suspected pathogens.
» Supporting the epidemiological and environmental investigations in detecting
the pathogen and understanding how the outbreak occurred.
» Working with other members of the investigation team to identify and character-
ise the pathogen involved in the outbreak.
Table 3.1 indicates the role of laboratory investigation in different types of outbreaks.
Figure 3.1 and Figure 3.2 illustrates the laboratory response management involved in a
disease outbreak in animals and humans.
46
LABORATORY INVOLVEMENT
Table 3.1. Role of laboratory investigation in different outbreak types

OUTBREAK TYPE ROLE OF LABORATORY INVESTIGATION
Common event Laboratory investigation has an important role in the
overall investigation of common event outbreaks.
Laboratory investigation is important in confirming
diagnoses, indicating possible sources and testing
environmental specimens. This includes testing of
clinical specimens from humans and animals as well
as from food, water and the environment
Common site Laboratory investigation of common site out-
breaks contributes to the identification of links
between cases, confirming diagnoses, indicating
sources and testing specimens
Dispersed Laboratory investigation of dispersed outbreaks
has a particularly important role in identifying
links between dispersed cases, as well as eventu-
al testing of sources, once identified
Community-wide Laboratory investigation of community-wide out-
breaks is important in identifying links between cases
Institutional Laboratory investigation has an important role in
the overall investigation of institutional out-
breaks. It is important in confirming diagnoses,
identifying links between cases, indicating possi-
ble sources and testing specimens
Source: Guidelines for the Investigation and Control of Disease Outbreaks by Institute of Envi-
ronmental Science and Research (website www.esr.cri.nz)
3.2 Pre Analysis

3.2.1 Consult the laboratory early
The laboratory should be alerted as soon as the need for outbreak investigation is suspect-
ed. The laboratory will identify liaison personnel for on-going consultation, so that conti-
nuity throughout the outbreak investigation and response is maintained. Initial discussions
should include defining the laboratory’s contribution, and should extend to inviting a lab-
oratory representative to join the outbreak team. Early communication would enable the
laboratory to schedule resources. At this time, investigators should request the laboratory
to save any relevant specimens from diagnostic testing work (before they are discarded)
and/or to refer the specimens for additional testing if necessary.
3.2.2 Estimate turnaround time

It is a good idea to have an estimate of the turnaround time for testing and when results
will become available. Follow-up results and their interpretation by the laboratory is im-
portant, and it may be necessary to discuss additional testing (remember that tests requir-
ing culture of microorganisms will take time).
47
ONE HEALTH MANUAL
Alert Emergency Response /

Management Team
Field Investigation Team

Operation Room
Inform Sample
Arrival
Laboratory
Lab. Operation Room

Lab. Testing Processing Registration
Isolation and Confirmatory Test

Identification
+ or - Sample
+ Sample + or - Sample
Characterization +/- Sample

Expert meeting and decision
Test Report
Director General of DVS
Figure 3.1 Laboratory response management in animal disease outbreak
Source: VRI
48
Alert of impending outbreak by

PKD or CPNRC Field Investigation Team Hospital Management Team
from DHG
Sample Collection
Begin Preparation for possible Collection of Samples from
Inform Sample
outbreaks according to disease admitted patients
Arrival
suspected
REFERENCE LABORATORIES (MR/MKA)

Local Hospital /
Lab. Testing Processing Registration State Laboratories
Registration
Isolation and
Identification Other Confirm
Other confirmatory
storyTest
Test
PCR/ Serology
PCR/Semology PerformSemological
Perform Serological
Screening
Screening and
and Culture
Culture and
and Sensitivity
Sensitivity
Characterization
Characterization Expert meeting and decision
serotyping/genotyping
Semotyping/genotyping
Test Report
PKD/CPNRC/KKM
Figure 3.2 Flowchart of laboratory involvement for human samples

3.2.3 Biosafety and biosecurity for safe handling of the specimens
Laboratory and outbreak response team personnel should be trained in appropriate bio-
safety measures, sample collection and transportation, and disposal of biohazard materi-
als. As a first step in establishing an archive, a laboratory bio-risk assessment addressing
biosafety and laboratory biosecurity issues, including any control or mitigation measures
to be implemented, must be completed. The laboratory should consider all bio-risk man-
agement measures needed to protect the integrity of the sample, as well as the health of
the workers and environment, from the time the original sample is received through the
long-term storage and ultimate use or destruction of the material(s). The appropriate level
of laboratory biosecurity, including controlled access to the archived samples and invento-
ry records, is an important consideration for laboratories maintaining biological invento-
ries and archives.
The laboratory should also have a back-up plan for the transfer or destruction of potential-
ly dangerous archived materials in the event of power failures or other compromises to the
storage environment. Refer to the Malaysia Laboratory Biosafety and Biosecurity Policy and
49
ONE HEALTH MANUAL
guideline, Ministry of Health Malaysia, 2015 at the following link http://mkak.moh.gov.my/

download/Biosafety_Policy_and_Guideline_2015.pdf, WHO Laboratory Biosafety Manual,
WHO Laboratory Biosecurity Guideline http://www.who.int/csr/resources/publications/bio-
safety/en/Biosafety7.pdf and OIE Biosafety & Biosecurity in Veterinary Laboratory http://
web.oie.int/eng/normes/MMANUAL/2008/pdf/1.1.02_BIOSAFETY.pdf for details.
3.2.4 Preparation for specimen collection

As part of the outbreak plan, specimen collection kits should have been already assem-
bled in preparation for an outbreak. The equipment in a field investigation should be por-
table and suitable for a range of situations and specimens. A checklist should be prepared
based on general tools/equipment, tools for food, water and environmental specimens,
tools for clinical specimens. Refer to Appendix 3.1 for Outbreak Investigation Laboratory
Guideline Checklist.
Laboratory investigation of a disease is critically dependent on the quality and appropri-

ateness of the specimens collected for analysis. Sampling may be from human, animals
and the environment for a variety of purposes, such as disease diagnosis, disease surveil-
lance, health certification, and monitoring of treatment and/or vaccination responses.
Wherever appropriate, the relevant authorities should be informed regarding specimen

collection (e.g. state health authority, PERHILITAN). Specimens must be collected using
appropriate biosafety and containment measures in order to prevent contamination of the
environment, animal handlers, and individuals involved in the sampling process as well as
to prevent cross-contamination of the specimens themselves.
For serological testing, paired sera are commonly needed; therefore a second (convales-
cent) specimen may be required about four-to-six weeks after the first (acute) specimen.
Identification details written on specimens and laboratory request forms must be legible
and as comprehensive as possible. Providing additional information about the case and
investigation on the request form is also important as it assists those performing the tests.
For example, for diarrhoeal specimens the suspect food source, incubation period, symp-
toms and a history of recent overseas travel should be recorded.
Adequate precautions must be taken when collecting clinical specimens to protect the col-
lector from the transmission of hazardous agents. These include standard precautions such
as wearing gloves, gowns and masks where appropriate, and taking necessary care during
collection of the specimens themselves. Specimens also need protection from contamination.
Graphical and detailed illustration of how to collect different range of specimens from
human cases is provided in Appendix 3.2 for the checklist of different range of specimen.
3.2.5 Storage and transport

After sample collection, the two key aims of storage and transport are to keep the spec-
imens viable and to minimise contamination. Most specimens are stored at refrigerator
temperature (2°C to 4°C), not frozen.
50
For transportation outside of the laboratory environment, an overnight courier or other

faster means should be employed with the use of chiller pads and insulated containers
to keep the specimens cool. Some specimens which must be transported at room tem-
perature, detailed instructions about specimen storage while awaiting transport to the
laboratory must be given. This is to ensure that the exposure to other household mem-
bers is minimised and the viability of the organisms is maintained. Refer to the Stan-
dard Operating Procedure for transport of biological specimens in Malaysia in the fol-
lowing link http://www.imr.gov.my/en/component/content/article/77-english-content/
services/1472-idrc-sop-for-transportation-of-biological-specimens.html
3.2.6 Sample processing

Sample processing is subjected to the specific samples and testing according to the avail-
able guidelines for the specific diseases.
3.3 Analysis
3.3.1 Laboratory diagnosis
Laboratory diagnosis is subjected to the specific samples and testing according to the
available guidelines for the specific diseases which may include culture, immunodiag-
nostics (antibody/antigen detection), molecular techniques and electron microscopy.
(Appendix 3.3)
3.3.1.1 Organism Typing Techniques

Organism typing will describe the detail characteristics of microorganisms of the same
species and allow further subdivision into different organism types or subtypes. Organ-
isms that are indistinguishable by typing are said to have epidemiological relatedness,
and are therefore more likely to have come from a recent common ancestor and common
source. This information can be used to link disease cases to assist in the identification,
description and investigation of outbreaks. In addition, disease cases can be linked to en-
vironmental samples to determine potential sources of infection.
3.3.1.2 Advantages of organism typing

An important advantage is the enhanced sensitivity for detecting dispersed outbreaks like-
ly to have emerged from a common source. Subtyping can contribute directly to the iden-
tification of the source of outbreaks. Another advantage is the enhanced ability to identify
causal links between implicated environmental sources and human/animal illness. Differ-
entiation of outbreak-associated isolates from isolates not related to the outbreak, even
among cases present in the same locality at the same time.
3.3.1.3 Limitations of organism typing

An important limitation is the additional time delay pending typing results. Epidemiolog-
ical investigation should not be delayed until typing results become available. However,
in the analysis of samples from a large multiple centres during a large epidemic/outbreak
where the strain type is very common, results from molecular typing are required to nar-
row the case definition and exclude non-related cases.
51
ONE HEALTH MANUAL
Another limitation is discrimination, the inability of the system to sufficiently differentiate

between organism types.
Reproducibility is also a limitation, most laboratories only use tests that are highly repro-
ducible. It is recommended that advice is sought from the appropriate reference laboratory
on the practicality and applicability of typing methods. Typing methods are grouped into
two main categories, phenotypic and genotypic.
Table 3.2: Categories of typing methods

TYPING METHOD TYPE OF ORGANISM EXAMPLE
Phenotypic (based on function and visible traits of the organism)
Antimicrobial suscepti- Bacteria Methicillin-resistant Staphylo-
bility coccus aureus
Biotyping Bacteria Shigella sonnei, Yersinia
enterocolitica
Serotyping Some bacteria and Salmonella spp, Neisseria
viruses meningitidis, E. coli (VTEC)
Phage typing Bacteria Salmonella spp, e.g. S.
Typhimurium, S. Enteritidis and
S. Typhi aureus
Biochemical profile Bacteria E. coli, Shigella spp., Vibrio
cholerae
Genotypic (analysis of nucleic acids within the organism)
PCR (detection of specif- Bacteria E. coli (VTEC), V. cholerae
ic virulence/toxin genes)
Pulsed-field gel Bacteria and fungi E. coli (VTEC), Listeria
electrophoresis (PFGE) monocytogenes, Salmonella
spp., Shigella spp.,
Campylobacter, V. cholerae,
Yersinia pestis
Restriction fragment Bacteria and viruses Mycobacterium tuberculosis
length polymorphism
(RFLP) and probing
MLVA, MLST often Bacteria Within some phage types of S.
being Typhimurium
included in investigations
where PFGE analysis is
not sufficiently
discriminative
DNA sequencing Bacteria and viruses Noroviruses
Plasmid profiling Salmonella
spp.
Source: Guidelines for the Investigation and Control of Disease Outbreaks by Institute of
Environmental Science and Research (website www.esr.cri.nz)
52
3.3.2 Interpretation and reporting of laboratory results

Laboratory test results are generally used to support a diagnosis or hypothesis and not to
make it. Testing may not be 100% accurate because methods have to balance sensitivity
and specificity. True positive results cannot determine causation to an absolute certainty.
Therefore, a positive result from a person or animal without epidemiological association
does not prove the person or animal was a source or vehicle of infection.
Positive result from an epidemiologically implicated person or animal strongly suggests

that person or animal was most likely a source or vehicle of infection.
Negative results do not deny an association, but indicate only that the pathogen is not
found in the specimen collected. Possible reasons, apart from the pathogen truly not exist-
ing in the specimen source, include:
• intermittent or non-uniform inoculation of the pathogen in the specimen, for exam-
ple, due to intermittent faecal shedding of pathogens
• specimen size is too small
• competitive microorganisms outgrew pathogen (if culture)
• item / source not tested for pathogen
• diminished, injured or inactivated pathogen due to inappropriate processing, han-
dling or storage
• for human faecal specimens, elimination of the pathogen may have already occurred
• inappropriate or inadequate laboratory methods
• agent is not a pathogen, for example, it could be a toxin
• agent is an emerging pathogen not detectable by currently available laboratory
methods.
If an organism or type of organism different to the ‘outbreak strain’ is found, this may still
provide evidence for a contamination or infective process and should be investigated fur-
ther. Reports from various laboratories (human, animal and environment) should be com-
municated with the Outbreak Team for final diagnosis.
3.4 Recommendations Based on Laboratory Investigations

In a common event or dispersed outbreak of foodborne or waterborne illness, the role of
laboratory investigation is to:
• confirm the diagnosis
• help identify the source
• establish links between cases using phenotypic or genotypic testing (particularly
dispersed outbreaks).
In an institutional outbreak, the role of laboratory investigation is to:

• help to identify the source.
In an environmental outbreak, the role of laboratory investigation is to:

• establish environmental contamination and its source.
53
ONE HEALTH MANUAL
In community-wide, person-to-person outbreaks, the role of laboratory investigation is to:

• establish links among the cases.
3.5 Management of Clinical Wastes
Identify and properly dispose of bio-hazardous and medical waste. Disposal procedures
depend on whether the waste is classified as bio-hazardous or medical waste.
• Bio-hazardous waste, also called infectious waste (such as blood, body fluids, and
human cell lines), is waste contaminated with potentially infectious agents or other
materials that are deemed a threat to public health or the environment.
• Medical waste is waste generated in labs or clinical settings that is not contaminated,
but could appear hazardous to outsiders.
Contamination determines the disposal method:

• Contaminated biohazard waste must be collected by a licensed bio-hazardous waste
hauler.
• Non-contaminated waste can be disposed of as medical waste.
Bio-hazardous waste includes the following categories:
• Sharps, including but not limited to hypodermic needles, blades, and slides.
Dry bio-hazardous waste

• Contaminated cultures, petri dishes, and other culture flasks
• Infectious agents
• Wastes from bacteria, viruses, spores, or live and attenuated vaccines
• Waste contaminated with excretion, exudates, or secretions from infectious humans
or animals
• Paper towels, Kim wipes, bench paper, or any other items contaminated with bio-
hazard materials
Liquid bio-hazardous waste
• Human or animal blood
• Human or animal blood elements
• Human or animal bodily fluids or semi-liquid materials
Anatomical specimens
• Animal and human carcasses and body parts if exposed to bio-hazardous materials
Medical waste includes the following:
• Non-contaminated cultures, petri dishes, and other culture flasks
• Non-contaminated syringes (no needles!)
• Decontaminated (i.e., autoclaved) dry biohazard waste
• Empty specimen containers
• Bandages or dressing containing dry blood or body fluids
• Trace chemotherapy waste, including empty containers and IV tubing
• Animal carcasses and body parts
• Any material resulting from medical care that is not bio-hazardous
• Any equipment used in a biomedical lab that could appear hazardous
54
Refer to the Guidelines on the handling and management of clinical wastes in Malaysia
at the following link http://ibbc.um.edu.my/images/ibbc/doc/anagement_Of_Clinical_
Wastes_In_Malaysia_2_0.pdf for more details.
CASE SCENARIOS
Case Scenario 1
Leptospirosis Outbreak
A large group of students from various schools in Melaka State Cadet Corp and their train-
ers went for a camping trip at a waterfall located in Hulu Langat. Two weeks later, 175
of them had fever associated with productive cough. Fourteen were admitted to Hospital
Melaka including 3 who were admitted to the Intensive Care Unit (ICU) and the rest were
managed as outpatients. The 3 patients admitted to ICU had more severe manifestations.
They developed acute respiratory distress and one patient had pulmonary haemorrhage.
Serum samples from all 175 patients were collected and sent to the Institute for Medical
Research to confirm the suspected leptospirosis outbreak. Forty-seven were positive for lep-
tospirosis where anti leptospiral antibody were either detected positive at a titre of ≥ 400,
or there were four-fold rise in titre when second samples were tested. Twenty-eight sam-
ples were from patients who were probably also infected but results were not conclusive
in the absence of second samples. Results were negative for 100 other patients but second
samples were not collected for 88 of these patients and therefore they may still be possibly
infected but laboratory confirmations were not possible in the absence of second samples.
From this outbreak, there are a few points to be noted where the laboratory can be in-
volved to improve outbreak investigation and source tracking:
1. Second serum samples were obtained only from 33 patients, and leptospirosis
was confirmed in 21 patients only when second samples were tested. Otherwise,
only 26 cases had antibody titres beyond 400 in their first samples. Therefore,
this illustrates the importance of repeat samplings for antibody detection.
2. During this particular outbreak, samples were not collected for detection of
DNA by polymerase chain reactions. If this test were performed, most likely
more cases would be detected and detection could have been made earlier.
3. It is worth doing culture to isolate pathogen from patients as this would be im-
portant for source tracking and in improving investigation of future outbreaks.
4. Investigation should include rat trappings and detection of carriers among cap-
tured rodents.
5. Environmental samples taken at the time of investigation may not reflect the
real infecting pathogenic serotypes or genotypes but it would be worthwhile to
isolate pathogenic leptospires from the areas suspected as source of outbreak.
Case Scenario 2
Brucellosis Outbreak
An outbreak of brucellosis occurred in Penang from March 2011 to March 2012. The in-
dex case was a 45-year-old goat farm owner who presented to Penang General Hospi-
tal with a 3-week history of fever, headache, severe lethargy, poor appetite, and exces-
55
ONE HEALTH MANUAL
sive sweating. He owned more than 300 goats and sold raw and unpasteurized milk to
the public. He had also been consuming the raw milk on a daily basis for several months.
Initially, he was investigated for other tropical diseases including dengue fever, malaria,
leptospirosis, and scrub typhus, but the tests returned negative. Blood culture isolated no
pathogen. Based on the history of raw milk consumption, a Brucella serology test was
ordered. The particle agglutination test for Brucella was strongly positive. He was started
on oral doxycycline and rifampicin. His fever eventually subsided and he was discharged
well. Following this, another 83 patients presenting with prolonged fever and nonspecif-
ic constitutional symptoms were diagnosed with brucellosis. Of the 63 retrieved patient
notes, two were workers on the farm. However, confirmation if they had contracted the
disease through animal contact or consumption of the raw milk was ambiguous. All but
four of the other patients had consumed milk bought from the same farm. The four pa-
tients were hospital laboratory staff who had presumably contracted the disease during
handling of the blood samples.
Diagnoses were confirmed using serology (87.3%), blood culture (69.8%), polymerase chain
reaction (17.5%), or tissue culture tests (1.6%). Brucella enzyme-linked immunosorbent
assay (ELISA) immunoglobulin M (IgM) and IgG kits from Vircell (Granada, Spain) were
used for detection of antibodies against Brucella. The patients had a mean age of 44 years
and more than half (57.0%) of them were males. The mean duration from onset of symp-
toms to diagnosis was 53 days with a maximum duration of 210 days. The most commonly
presenting symptom was fever, followed by fatigue, arthralgia, myalgia, low-back pain, and
night sweats. Almost half (47.6%) of the patients had anaemia and 12.7% had raised alanine
transaminase. Three patients had spondylitis, whereas another two males developed orchitis.
A man was admitted to the Cardiology Department for infective endocarditis and his blood
culture subsequently isolated Brucella. Unfortunately, he was lost to follow up after receiv-
ing treatment. Majority (88.6%) of the patients had systemic illness.
Points to note in this scenario: When the first case was confirmed as brucellosis, extra
precaution should have been taken in handling samples from other patients with suspected
brucellosis after consumption of milk from the same farm. This would have prevented the
laboratory acquired brucellosis that occurred during this period. Once suspected, the sam-
ples for culture should be carried out in laboratory with BSL3 facilities.
Source: Leong et al., Case Report: Outbreak of Human Brucellosis from Consumption of Raw
Goats’ Milk in Penang, Malaysia. Am. J. Trop. Med. Hyg., 93(3), 2015, pp. 539–541
Case Scenario 3
Highly Pathogenic Avian Influenza (HPAI) Outbreak in village chicken in Malaysia, 2004
On 17th August 2004 there was a new index case of HPAI located at Kampong Pasir Pe-
kan, Tumpat Kelantan located 22 km from the border of Thailand. The outbreak occurred
in a flock of free-range village chickens consisting of 60 birds of mixed ages.
56
Figure 3.3 Maps showing location of outbreak in Kampong Pasir Pekan,

Tumpat, Kelantan in Malaysia (above) and its location in the region (below).
The owner reported to the Department of Veterinary Services (DVS) Kelantan that about
50% of his chicken died. An investigation was done by DVS Kelantan at the foci in the
same day. Two chickens were found dead in the chicken house and were subjected to nec-
ropsy. Pooled organs sample was collected and sent to Veterinary Research Institute, Ipoh
for laboratory diagnosis. The farm was quarantined and sealed to prevent any in and out
movement of animal and human. Laboratory result was released on the same day. The
test method was RT-PCR. The result revealed that HA gene was found corresponded to
the correct size of avian influenza sub-type H5. The outbreak of highly pathogenic avian
influenza (HPAI) in Malaysia was reported to the OIE on August 19, 2004 which was the
first case in the country. However the clinical signs and post mortem findings were not
truly prominence as HPAI infection. It may be due to the chicken dying acutely.
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Table 3.4: Confirmation of AIV Sub-type H5N1 from Index Case

DATE TEST RESULTS
17 August 2004 RT-PCR product of HA gene was found. It corresponded to the
correct size of avian influenza sub-type H5
19 August 2004 RT-PCR product of HA gene was found. It corresponded to the
correct size of avian influenza sub-type N1
20 August 2004 Nucleotide sequence of HA gene of the AIV H5N1 isolated from
Pasir Pekan was confirmed similar (97 % homology) with H5N1
isolated in Thailand and Vietnam (2004)
The Director General of DVS declared the outbreak to public through the press confer-
ence and press release. All control and eradication procedure were intensely carried out.
Table 3.5: Policy on Handling HPAI Outbreak

ITEM POLICY
Eradication Stamping out – all chickens, ducks and birds within 1 km
radius of infection/outbreak location
Intensive Active surveillance within 10 km radius (the next 9 km) of
surveillance infection/outbreak location
Movement control Prohibition on movement of chickens, ducks and birds, and
their products from Kelantan or infected state to other states
Notification and Any abnormal mortality of chickens, ducks and birds of more
case definition than 3 % must be notified and investigated. Such notification
will trigger ERM.
Diagnostic and RRT-PCR and RT-PCR are considered as confirmatory tests.
confirmatory test Both tests can be conducted at Veterinary Research Institute
in Ipoh or Veterinary Faculty, UPM. NASBA test is used for
screening purpose.
Compensation All chickens, ducks, birds and eggs culled/destroyed will be
compensated by the government.
Vaccination Vaccination is not allowed.
58
Pictures showing culling of birds and disinfection process surrounding infected areas.
59
ONE HEALTH MANUAL
Figure 3.4 Map showing the movement and control measures

On 5th September 2004 there was another case of high chicken mortality reported at
Kampung Belian, Sungai Pinang Tumpat, Kelantan and confirmed H5N1 by laboratory
diagnosis. A total of 11 subsequent cases detected and reported until the end of 2004. One
case detected positive in healthy chicken.
Subsequent outbreaks and detection of HPAI virus (17 August to 12 December 2004)
Figure 3.5 Map showing the outbreak and detection of HPAI from healthy Avian
60
Figure 3.6 Numbers of outbreaks and detection of AIV

Variation in Flock Mortality Rate (%)
* In Kuchelong the 5 village chickens involved were sick and still alive during inspection
Figure 3.7: Variation of flock mortality rate amongst locality of outbreak.
Poultry industry in Malaysia was severely affected and almost ruined due to the outbreak.
Malaysia had 170 million chickens and 13 million ducks in 2003, accounting for about
1% of world stocks each. Malaysia exported substantial numbers of live poultry in 2001
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ONE HEALTH MANUAL
and 2002, exports of live chickens and ducks in 2002 accounted for 6.1% and 51.7% of
world exports, respectively. Exports of eggs were also significant, accounting for 11.4%
of world exports. Most of the live birds and eggs are exported to Singapore.
Compensation
Mechanism and rate for compensation scheme has been formulated. The compensation
was dispensed by DVS to the affected farmers and bird keepers.
Source: Dr. Kamarudin Md. Isa (2004), Malaysia Experience on Control of HPAI and Lesson
Learnt, In: Japan-Thailand Technical Cooperation on Animal Disease Control in Thailand and
Neighbouring Countries at http://yk8.sakura.ne.jp/ADC-1/Pages/AI%20seminar%2004/Malay-
siaAI1.html, retrieved on 26 April 2016.
Case Scenario 4
Nipah Virus Outbreak in Malaysia
An outbreak of human acute febrile encephalitis with high fatality in pig-farms in the sub-
urb of Ipoh, Perak in Peninsular Malaysia was reported in late September 1998. This was
preceded by the occurrence of respiratory illness and encephalitis in pigs. The outbreak
was initially attributed to Japanese encephalitis (JE) because 4 serum samples from 28 pa-
tients in this outbreak area tested positive for JE-specific IgM (subsequently confirmed by
the WHO Collaborating Center for Tropical Disease at the University of Nagasaki, Japan)
and JE nucleic acids were detected in some of the patients’ sera by reverse-transcriptase
PCR carried out at the Arbovirus Unit of the University of Malaya. Early control mea-
sures, including anti-mosquito fogging and vaccination of pigs against JE, were ineffec-
tive. 15 fatalities, 9 of whom were subsequently confirmed to have Nipah virus infection
at autopsy were reported in Ipoh.
Unfortunately, pig-farmers affected by the outbreak sold pigs to other farms across the
country. By February 1999, the outbreak had spread to Sikimat, Sungai Nipah Village and
Bukit Pelandok (the largest pig-farming communities) in Negeri Sembilan, some 300 km
south of Ipoh. This second and more severe epicenter contributed some 180 patients and
89 deaths. With further surreptitious movement of infected pigs, cases also emerged from
Sepang and Sungai Buloh in Selangor. In March 1999, 11 cases, with 1 death, were re-
ported among abattoir workers in Singapore who handled pigs imported from Malaysia.
By then the outbreak had caused nationwide public fear, and near collapse of the local
pig-farming industry.
Healthcare workers looking after the patients had been convinced relatively early in the
outbreak that this was not due to JE. Unlike JE, adults were affected rather than children,
and many victims had previous immunisation against JE. The autopsy findings were not
consistent with the usual findings in JE, suggesting some other agent. Many victims had
direct physical contact with pigs, unlike a mosquito-borne disease. It was the isolation
of the Nipah virus (NiV) from the cerebrospinal fluid (CSF) of an outbreak victim (from
Sungai Nipah village) by a medical virologist at the University of Malaya in early March
1999 that brought acknowledgement that the infection was caused by an agent previously
unknown to science. Together with the Hendra virus (HeV), the novel virus is now rec-
ognised as a new genus, Henipavirus (Hendra + Nipah), in the Paramyxoviridae family.
62
It was shown that NiV and HeV shared enough epitopes for HeV antigens to be used in a
prototype serological test for NiV antibodies. This helped tremendously in the subsequent
screening and diagnosis of NiV infection.
The outbreak in Singapore ended with prohibition of importation of pigs from Malaysia
and closure of abattoirs. The outbreak in Malaysia ceased with widespread surveillance
of pig populations, and the culling of over a million pigs. The last human fatality occurred
on 27 May 1999. By then, 265 cases of acute NiV encephalitis with 105 deaths had been
recorded in Malaysia, giving a mortality rate of nearly 40%.
Lessons from the outbreak:

1. Communicating or announcing the cause of outbreaks should be done by an
appointed scientific liaison. Conflicting announcements can hamper effective
outbreak measures.
2. A new disease may resemble and thus be mistaken for a familiar one. If not
for medical doctors keeping an open mind on new possibilities, the novel virus
would not have been discovered and the devastation from the outbreak would
have been far more severe.
3. Free sharing of information and cooperation among scientists and medical doc-
tors, both locally and internationally, was one of the most positive aspects of the
outbreak. Without this willingness to share and help, the virus would not have
been characterized so rapidly nor effective surveillance and control measures
devised so quickly. It is noteworthy that the outbreak, which had raged for 6
months, was controlled 2 months after the discovery of the virus.
4. The pro-active decision by the Government of Malaysia to compensate pig-farm-
ers for the loss of pigs was crucial in stopping the surreptitious smuggling of
pigs out of outbreak areas, and acceptance of massive pig-culling in all affected
communities.
5. There should be frequent surveillance of the pig population for evidence of fresh
infection.
6. Subsequent Nipah outbreaks in Bangladesh and India make it likely that there
will be more future outbreaks in Asia. Inter-governmental cooperation to pre-
vent anthropogenic and environmental activities that can lead to its re-emer-
gence is crucial.
Source: Looi, L. and Chua, K. (2008) ‘Lessons from the Nipah virus outbreak in Malaysia’, The
Malaysian journal of pathology, 29(2), pp. 63–7.
Case Scenario 5
Plasmodium knowlesi Outbreak
On 28 April 2007, a 20-year-old national serviceman working in Singapore sought med-
ical treatment for fever, myalgia, anorexia, nausea and vomiting. On further questioning,
he had a training in a forested area inhabited by the long-tail macaques (M. fascicularis)
in Lim Chu Kang. Blood smears showed morphological features of P. malariae. Howev-
er, as he had daily spikes of fever and marked symptoms were not consistent with P. ma-
lariae infection, further investigation was conducted to confirm the etiology. Polymerase
chain reaction (PCR) studies using Plasmodium knowlesi-specific primers, followed by
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ONE HEALTH MANUAL
sequencing and phylogenetic analyses were done and confirmed P. knowlesi infection.
Epidemiological investigations based on his movement history showed that the infection
was most probably acquired in the forested area at Lim Chu Kang, Singapore. Subse-
quently, another 2 soldiers from the same army camp with similar clinical features and
movement history were also confirmed to be infected with P. knowlesi.
These 3 cases are considered an “outbreak” in Singapore based on the local surveillance data.
Points to note in this scenario:

1. Clinical judgement by clinicians, and good communication between clinical mi-
crobiologists and their laboratory staff are of utmost important. The sample was
immediately sent for molecular detection to differentiate between P. malariae
and P. knowlesi.
2. Further fieldwork studies are required to determine the vectors and reservoir of
infection and effects of deforestation in Lim Chu Kang area.
Source: Lee YC et al., Epidemiological characteristics of imported and locally-acquired malar-
ia in Singapore. Ann Acad Med Singapore. 38(10), 2009, pp. 840-849.
64
BIBLIOGRAPHY
AFENET. Outbreak Investigation Laboratory Guidelines. [Online]. The African Field
Epidemiology Network Available: http://www.afenet.net/downloads/outbreak_manul_
web.pdf [Accessed August 9 2016].
KAMARUDIN, M. I. 2004. Malaysia Experience on Control of HPAI and Lesson Learnt.

In: Japan-Thailand Technical Cooperation on Animal Disease Control in Thailand and
Neighbouring Countries
[Online]. Available: http://yk8.sakura.ne.jp/ADC-1/Pages/AI%20seminar%2004/Malay-

siaAI1.html [Accessed April 26 2016].
LEE, Y. C. A., TANG, C.S., ANG, L.W., HAN, H.K., JAMES, L. AND GOH, K.T., 2009.
Epidemiological characteristics of imported and locally-acquired malaria in Singapore.
Annals Academy of Medicine Singapore, 38(10), 840.
LEONG, K. N., CHOW, T.S., WONG, P.S., HAMZAH, S.H., AHMAD, N. AND
CH’NG, C.C., 2015. Outbreak of Human Brucellosis from Consumption of Raw Goats’
Milk in Penang, Malaysia. The American journal of tropical medicine and hygiene, 93(3),
539-541.
LOOI, L. M. and Chua, K.B., 2007. Lessons from the Nipah virus outbreak in Malaysia.
Malays. J. Pathol, 29, 63-67.
MERCK. The Merck Veterinary Manual [Online]. Available: http://www.merckvetmanu-

al.com/mvm/index.html [Accessed August 9 2016].
MOHAMED, R. 2010. Laboratory Response Management in Veterinary Research Insti-

tute (unpublished).
WHO. How to safely collect blood samples from persons suspected to be infected with
highly infectious blood-borne pathogens. [Online]. World Health Organization. Avail-
able: http://www.who.int/csr/resources/publications/ebola/blood-collect-en.pdf [Accessed
August 9 2016].
65
CHAPTER FOUR
DEVELOPING,
EVALUATING AND
REFINING HYPOTHESES
Assoc. Prof Dr Razitasham Safii, Dr Mohammad Saffree Jeffree,

Dr Hayati Binti Kadir @ Shahar, Dr Akma Binti Ngah Hamid,
Dr Siti Zubaidah Ramanoon, Dr Sylvia Daim
ONE HEALTH MANUAL
4.0 Introduction
The aim of the chapter is to describe how to generate and evaluate hypothesis by conduct-
ing an analytical study design to identify the risk factors that contribute to the outbreak.
When an outbreak has been identified, demographic, clinical and/or laboratory data are
usually obtained from the Health and/or Veterinary Department, clinicians, or laboratory
experts. These data are organized in a line listing for human cases or Animal Disease
Information Centre (ADIC) for animal cases. Prior to generating a hypothesis, descrip-
tive analysis must be conducted. This descriptive analysis will include outbreak charac-
teristics by time, place and person/animal from the line listing or ADIC. Data can also
be obtained from literature reviews about the disease concerned to identify potential risk
factors. Based on the information gathered in the line listing and the literature reviews,
a specific hypothesis is developed. Reviewing the medical, epidemiology, and veterinary
literature (where relevant) and talking to other experts in the field to learn about previous
similar outbreaks can provide valuable insight into the potential causative agent(s) and/or
exposure(s).
Hypothesis statement should consist of the assumption of the agent, source and spread of
the outbreak. The statement must be clear and be able to answer the questions on what,
where, when, who, why and how should be tested using an analytical epidemiology study
design usually a case control or a cohort study.
4.1 Developing a Hypothesis

Hypothesis should be developed guided by descriptive information derived from the line
listing/ADIC and also information learned from past outbreaks. However, it is important
to keep an open mind and be prepared to consider other possibilities. From the prelim-
inary data that have been collected and line listing that has been created, investigators
should have enough information for further analysis with regards to why (associated risk
factors) and how (the inter-relationship of people/animal, agent and environment) the
outbreaks occur.
In generating hypothesis, one must also consider this information:

(i) what is known about the biology of the disease (the cause)
(ii) the mode of transmission
(iii) the length of incubation period
(iv) the infectious period
For example in a case of Rabies, further history will be needed from the Department of
Veterinary Services, Malaysia which may include:
(i) bitten by stray dog
(ii) bitten by owned dog
(iii) dogs from immune belt area have been vaccinated
(iv) licensed dog
(v) vaccination status of owned dogs
(vi) any dog movement from neighbouring countries
(vii) dogs from outbreaks area
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DEVELOPING, EVALUATING AND REFINING HYPOTHESES
In generating a hypothesis, the information needed can be obtained through:

(i) interview during case investigation
(ii) spot map of the location of cases
(iii) the epidemic curve which will show incubation period and possible
mode of transmission (common source versus propagated).
All data collected through a hypothesis-generating questionnaire will further refine the
potential risk factors associated with the outbreak.
Case example 1: Rabies Outbreak in Perlis, Malaysia

On July 27, 2015, Rabies outbreak was declared in Perlis. The first case of a dog bite was
reported in one of the villages (Felda Lubuk Sireh) in Perlis, a village close to the bor-
der with Southern Thailand. The patient was presented with fever, headache and agitation.
This case was tested positive for Rabies. Subsequently, seven other cases were reported.
All the patients had a history of dog bites. During this period, all the dogs involved in bit-
ing the patients were captured and quarantined up to 14 days by the local Veterinary De-
partment. The decapitated heads of all the quarantined dogs that died were sent to the Vet-
erinary Research Institute (VRI), Ipoh for confirmation using Direct Fluorescent Antibody
Test (DFAT). The last confirmed case in the dog was reported on 21 September 2015.
Example of the hypothesis:

(i) Human health: Rabies outbreak is due to dog bites with possible source
of rabid dogs.
(ii) Animal health: Rabies outbreak amongst dogs with a possible source of
infection from a neighbouring country.
(iii) Final hypothesis statement, in this case, is “An outbreak of Rabies in
Perlis is due to rabid dog bites with a possible source of infection from
a neighbouring country”.
(iv) If the analytical study confirms the hypothesis, and confirmatory test
result by the Veterinary Laboratory is positive, then the final hypothesis
can be refined as:
(v) “An outbreak of Rabies in Perlis is due to rabid dog bites with the ori-
gin of infection from a neighbouring country”.
4.2 Evaluating a Hypothesis

In some outbreaks, descriptive epidemiology is sufficient to point to the source of infec-
tion, thus, further analysis is unnecessary. However, if the source is unclear, analytical ep-
idemiology must be utilized.
4.2.1 Study design

The results from the hypothesis-generating questionnaire will be used to test the hypoth-
esis in an analytic epidemiological study. There are two study designs that can be used:
(i) Cohort study
(ii) Case control study
The choice of the study design will depend on the outbreak situation. In practice, the de-
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ONE HEALTH MANUAL
cision is based on the outbreak population. If the population is easily identifiable, for ex-
ample school children whereby the investigator able to interview all of them, then a retro-
spective cohort study may be the best approach. If there is no obvious exposure among the
cases or involvement of large outbreak, then a case-control study may be the best choice.
Source: Outbreak Investigations. Available http://sphweb.bumc.bu.edu/otlt/MPH-Modules/PH/

Outbreak/Outbreak_print.html.
Case control study is a better choice when the source population is large and ill-defined
and in cases of a rare disease.
• Definition of cases - those patients diagnosed as having disease, example, rabies

(Data obtained from hospitals)
• Definition of controls - those patients bitten by a dog but no symptoms of rabies (Data
from hospitals and nearby clinics obtained through active case detection [ACD])
Table 4.1: Ratio of cases to controls
TOTAL NO. OF CASES IN AN CASES CONTROLS
OUTBREAK
>50 1 1
<50 1
*more than 4 controls per case-patient will not increase statistical power
70
For example, in a case of rabies the requirements for a case control study will be:
(i) Understanding the risk factors of rabies.
(ii) The possible source of infection (based on previous literature or out-
breaks in other locations or other countries).
Table of analysis to provide attack rate (AR), risk ratio, and odds ratio (OR) is depicted
below. Refer section 4.3.1 for formulae to calculate AR, risk ratio and OR.
Table 4.2: Hypothesis testing to determine risk factors
RISK FACTOR EXPOSURE CASES CONTROLS TOTAL
Bitten by stray dogs Yes
No
Bitten by owned dog Yes
No
Bitten by vaccinated Yes
dog from immune belt No
area
Bitten by vaccinated Yes
dog from non-immune
No
belt area
Bitten by licensed dog Yes
No
Bitten by dog from Yes
neighbouring countries No
Bitten by dog from out- Yes
break area No
4.2.2 Developing hypothesis generating questionnaire

Steps in creating a hypothesis generating questionnaire is listed below
(Source: North Carolina Center for Public Health Preparedness—The North Carolina Institute
for Public Health. Hypothesis Generation During Outbreaks. Volume 1, issue 6. Available on-
line: http://sph.unc.edu/nciph/focus/)
(i) Identify the leading hypotheses about the source of the problem
(ii) Identify the information needed to test the hypotheses
(iii) Identify the information needed for logistics of the study and to exam-
ine confounding
(iv) Write the questions to collect this information
(v) Organize the questions into a questionnaire format
(vi) Test the questionnaire
(vii) Revise the questionnaire
(viii) Train interviewers to administer the questionnaire
Field investigation questionnaires commonly include outbreak information on identifying the
respondent, demographic, clinical, exposure or risk factor, and the source (see Appendix 4.1).
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ONE HEALTH MANUAL
(i) For the logistics of the study, the respondent’s identification is import-
ant. The information that should be collected include name, other iden-
tifiers, current address, and telephone number. This information allows
updating of the questionnaire as well as linking to other records, such as
laboratory results. Identification of the person supplying the informa-
tion provides some insight into its validity.
(ii) Demographic information includes age, gender, educational level, occu-
pation and locality. These information enables the investigator to char-
acterize the population at risk, explore the problem under investigation
and the possible confounders.
(iii) Clinical information including signs and symptoms of the disease, date
of onset of illness, and results of laboratory testing. This information
allows the investigator to characterize the illness, decide who has the
outcome of interest, and chart the time course of the problem (timeline).
(iv) Exposure or risk factor information which is used to test the hypotheses
under investigation.
It should be specific to the problem under investigation and reflect the hypotheses con-
cerning the source of the outbreak. Exposure or risk factor information often includes the
respondent’s exposure, the route of exposure, the amount of exposure, the timing of expo-
sure, and other details of exposure (e.g., brand, distributor).
4.3 Data management

All the data collected should be entered into software such as EpiInfo, Microsoft Excel,
SPSS, STATA and any other relevant package. Data analysis include descriptive epidemi-
ology that focuses on “person, place, and time”. Characteristics of person, place, and time
are the essential elements for both descriptive epidemiology (to identify possible sources)
and for analytic epidemiology (to definitively identify the source).
4.3.1 Measurement of risk

(a) Cohort study design
In a cohort study, measurement of risk include attack rate and relative risk.
(i) Attack rate
Attack rate measures the speed of spread or frequency of a disease.
(ii) Relative risk
In a cohort study, risk ratio is calculated. Risk ratio measures the estimated
risk of the suspected exposure towards the disease.
(iii) Attributable risk
Attributable risk measures the risk of a factor to the outcome.
72
Table 4.3: Calculation of attack rate and risk ratio

EXPOSURE DISEASE
Yes No
Yes AR 1
No AR2
Attack rate 1 (attack rate in exposed group) = number of ills / number of exposed
Attack rate 2 (attack rate in non-exposed group) = number of ills / number of non-exposed
Risk Ratio = AR 1 / AR 2
= (Incidence in the exposed group) / (Incidence in the unexposed group)
Table 4.4: Interpretation of Relative Risk

RISK FACTORS
Relative Risk (RR) 95% CI P value
Interpretation of Relative Risk:

RR =1 means there is no association
RR>1 means there is an association. The higher the RR, the stronger is the association
of the exposure related to the case, this however is dependent on the confidence interval
(95% confidence interval does not include 1).
RR < 1 means protective factor.
An example of calculation of AR, RR and attributable risk for cohort study is depicted in
table below:
RISK FACTOR DEVELOP NOT DEVELOP TOTAL

RABIES RABIES
Bitten by stray Yes 7 3 10
dog No 3 7 10
Therefore,
(i) The attack rate is:

AR1 = 7/10 = 0.7=70%
AR2=3/10 = 0.3=30%
(ii) RR = AR1/AR2=0.7/0.3=2.3
95% CI = 0.83-6.54
Patients bitten by stray dogs are at two times higher risk to develop Rabies, however it is
not significant (as RR includes 1)
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ONE HEALTH MANUAL
(iii) Attributable risk

= AR1-AR2
= 0.7-0.3
= 0.4
An expansion of attributable risk measurement is proportional attributable risk percent
(AR%) that can be calculated as below:
Proportional AR (AR%) = Risk in exposed - Risk in non-exposed / risk in non-exposed

= 0.7-0.3/0.7
= 0.57
= 57%
Interpretation: 57% of incidence in stray dog bites exposed is attributable to being bitten
by stray dogs. Better interpretation for prevention of Rabies would be, Cases of Rabies
can be reduced by 57% if people were not bitten by stray dogs.
Case control study
Study population
Cases (50) Controls (50)
Exposed (40) Not exposed Exposed Not exposed (35)

(10) (15)
In case control study, the measurement of risk is odds ratio.

OR = (number of exposed cases) / (number of unexposed cases)
(number of exposed controls) / (number of unexposed controls
OR = 40 / 10 x 35 / 15 = 4 x 2.33 = 9.33
The odds of getting the illness is about 9 folds higher among the exposed compared to
non-exposed.
Interpretation of OR which is also known as estimated RR:

OR = 1 means there is no association
OR > 1 means there is an association. The higher the odds ratio, the stronger is the associ-
ation of the exposure related to the case, this again is dependent on the confidence interval.
OR < 1 means there is a decreased risk with the exposure.
An example of calculation of OR in a case control study is shown on the next page:
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RISK FACTOR EXPOSURE CASES CONTROL

History of bitten Yes 6 3
by stray dog No 4 7
Total 10 10
Therefore, OR = 6/4 /3/7

= 6 x 7/ 4 x 3
= 3.5
Interpretation: Those who are bitten by stray dogs are almost at four-folds higher risk to
develop Rabies than those not bitten by stray dogs.
4.4 Refining a Hypothesis

If the analytical study does not confirm any of the risk factors (e.g. OR =1 or confidence
interval includes 1) then there is a need to re-analyse the data from the descriptive epi-
demiology to look for other sources and routes of transmission. This may involve meet-
ing again with the case/patients or their contact(s) to look for common links. A visit to
the home may be required to analyse the environment. Further evaluation of the evidence
may provide the investigator more valuable information about the disease, its modes of
transmission, the characteristics of the agent, and host factors.
Example 1:
A case-control study failed to point towards a food source as a common vehicle in an in-
vestigation of a multi-state outbreak of Salmonella enteritidis involving 132 cases from 15
states across the United States between January and June 2016. Interestingly, infants aged
less than one year to 87-year-old adults were involved in this outbreak. This caused the
investigators to consider other vehicles of transmission to which persons of all age group
could be exposed. By asking about their exposure to live poultry in the week before their
illness, the investigators found that contact with poultry was the likely vehicle. Those ill
reported purchasing live baby poultry from several different suppliers, including feed sup-
ply stores, co-ops, hatcheries, and friends in multiple states. The sick people reported pur-
chasing live poultry to produce eggs, learn about agriculture, as a hobby, keep as pets, or
to give as Easter gifts. Some of the cases reported contact with live poultry at their homes,
someone else’s home, work, or school settings. Local health officials in Michigan collect-
ed environmental samples from live poultry at feed stores which was tested at the state lab
and the outbreak strain of Salmonella Enteritidis was isolated.
(Source: http://www.cdc.gov/salmonella/live-poultry-05-16/index.html).
Example 2:
Another example of laboratory study of outbreak investigation of Legionnaires’ disease
in Philadelphia 1977 was not considered complete until the new organism was isolated in
the laboratory over 6 months after the outbreak actually had occurred.
(Source: Fraser DW, Tsai TF, Orenstein W, et al. Legionnaires’ disease: description of an epi-
demic of pneumonia. N Engl J Med 1977;297:1189-97).
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ONE HEALTH MANUAL
An environmental study can often help explain why an outbreak occurred and may be
very important in some settings. For example, in an investigation of an outbreak of Sal-
monellosis enteritidis mentioned above, samples from live poultry and their environment
were collected at the Minnesota patient’s home. Four of six samples showed that poultry
purchased contained the outbreak strain of Salmonella enteritidis.
4.5 CASE STUDIES

Case study 1: Hypothesis Generation
In 1997, an outbreak of E. coli O157:H7 infection was reported in Michigan and Virginia,
United States. This bacterial strain of E. coli lives mainly in cattle (the reservoir), al-
though it has been found in deer, sheep and caribou. The bacterium passes from the res-
ervoir through faeces. Meat from the animals can be contaminated with bacteria during
slaughter, and when the meat is on the ground. Thus many E. coli O157:H7 outbreaks
have been associated with undercooked hamburgers. Faeces can also contaminate fruits
and vegetables, water, milk, and humans directly. Outbreaks have been associated with
consumption of unpasteurized apple juice or cider, consumption of lettuce, swimming in
water contaminated by cattle or humans, and direct contact with animals such as in pet-
ting zoos.
Knowing that any of these sources might be related to the outbreaks in Michigan and
Virginia, the investigators conducted hypothesis-generating interviews. They wanted to
see if any of the risk factors in previous outbreaks might be related to the current out-
break. They interviewed 7 case-patients and asked them about their diet and activities in
the 7 days (maximum incubation period) before their illness onset. The only common
risk factor found among the case-patients was consumption of lettuce and alfalfa sprouts.
Very few reported eating any meat or hamburgers. Their working hypothesis was: E. coli
O157:H7 outbreak was due to consumption of contaminated vegetables (lettuce, alfalfa
sprouts) or meat.
Another factor that supported the hypothesis of a vegetable source was the demographic
profile of the cases. From national surveillance data, the investigators knew that most
cases of E. coli O157:H7 infection occurs among children, and men are more likely than
women to be infected among adults. In the Michigan outbreak, nearly 70% of the cases
were women, and the median age was 31 years. This demographic profile led investiga-
tors to hypothesize that produce might be responsible for the outbreak rather than ham-
burgers. Their refined hypothesis was: E. coli O157:H7 outbreak was due to consump-
tion of contaminated lettuce or alfalfa sprouts. Prior to 1997, alfalfa sprouts had caused
outbreaks of salmonellosis, but not E. coli O157 infection. In Montana in 1995, lettuce
had been implicated in an outbreak and this was the leading hypothesis. However, to be
thorough, the investigators included a variety of toppings used in salads, including alfalfa
sprouts, in their questionnaire. To test their hypothesis, they used a case-control study. In
the analysis, alfalfa sprouts were found to be the strongest risk factor for infection in sep-
arate studies in Virginia (matched OR 25; 95% CI 4-537) and Michigan (matched OR 27;
95% CI 5-558).
76
Important learning point: is that if the investigators had relied only on previous known
risk factors rather than taking the time to generate a hypothesis through interviews with
patients, they would have missed the cause of this outbreak.
(Source: Breuer T, Benkel DH, Shapiro RL, et al. (2001). A multistate outbreak of Escherichia
coli O157:H57 infections linked to alfalfa sprouts grown from contaminated seeds. Emerg Infect
Dis [serial online] 2001;7(6):977-82. Available from: http://www.cdc.gov/ncidod/eid/vol7no6/
breuer.htm
Case Study 2: Cohort Study
In July 2007, an outbreak with unknown aetiology was reported to the local health unit
in Du¨ren, Germany. Initial investigation showed that all of the individuals involved in
the outbreak were seasonal strawberry harvesters from Romania, Slovakia, and Poland
who had gastrointestinal symptoms and had worked on a nearby farm. Thirteen persons
were hospitalized, and wide spectrums of pathogens were investigated without any posi-
tive results. Simultaneously, food samples from the farm were tested, and all had negative
results. Although the outbreak abated, serum samples obtained from 5 patients were even-
tually tested for leptospirosis; 3 samples had positive results, and leptospirosis was sus-
pected as the possible outbreak cause. An outbreak investigation was initiated to identify
the source of the outbreak and the possible risk factors for leptospirosis infection.
A retrospective cohort study was conducted in collaboration with the National Public
Health Institutes of Romania, Slovakia and Poland. Harvesters who were present on the
strawberry farm during the outbreak month (from the middle of June through the middle
of July) were identified by a list provided by the farm. Because these individuals had re-
turned home, the corresponding national health institute contacted them and asked them
to participate in the study. Participants were interviewed by health care workers using a
standardized questionnaire, which was translated into the local language. The question-
naire included information on demographic characteristics, work and travel history, clin-
ical information, and possible exposures during the outbreak month (including rodent
sightings and contact, the presence of wounds, consumption of unwashed strawberries,
and water activities). A confirmed case patient was defined as an individual who was
present on the strawberry farm during the period from 5th June through 8th September
2007 and who had fever and at least one other symptom and/or had received a diagno-
sis suggestive of leptospirosis (including renal impairment, meningitis, headache, flu-like
symptoms, and vomiting), as well as serological test results positive (≥1:800) for antibod-
ies against serogroup Grippotyphosa and a positive IgM antibody ELISA result. A sus-
pected case patient was an individual who was epidemiologically and clinically associated
with the outbreak for whom there was no serological confirmation of infection.
Of the 185 people included in the list, 184 were contacted, and 153 (83%) agreed to par-
ticipate in the study. Of the 153 individuals who agreed to participate, 77 (50%) were
Polish, 71 (46%) were Romanian, and the remaining 5 (4%) were Slovakian. Fifty-four
percent of the study participants were female, and the mean age of study participants was
33 years (range, 18–61 years). In total, 13 confirmed and 11 suspected cases occurred
from 19th June through 25th August 2007 among harvesters working in the largest straw-
berry field (19 hectares) belonging to a strawberry-producing farm near Du¨ren, a town
in North Rhine- Westphalia, Germany. The number of cases peaked in the first week of
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ONE HEALTH MANUAL
July. Fifty percent of all cases occurred in women, the median age of participants with
suspected or confirmed cases was 33 years (range 23–49), and 54% of participants with
suspected or confirmed cases were of Romanian origin. The overall attack rate was 16%
and did not differ between male and female study participants. Although individuals of all
ages from 20 years through 49 years were affected, the attack rate was highest amongst
individuals aged 25–29 years (attack rate, 30%).
In a cohort study such as this, investigators calculate and compare the risk of disease be-
tween the exposed and unexposed group, for each of the potential exposures associated
with disease occurrence. In so doing, investigator will obtain a Relative Risk or Risk Ra-
tio which tells the magnitude of risk of disease conferred by the exposure among the ex-
posed group, relative to the unexposed.
Eating unwashed strawberries (RR, 7.7; 95% CI, 1.1 – 55.4; P = 0.01), harvesting with
uncovered hand lesions (RR, 3.5; 95% CI, 1.6 – 7.4; P = 0.001), and accidental rodent
contact on the field (RR, 3.2; 95% CI, 1.5 – 6.7; P = 0.01) were risk factors for leptospiro-
sis infection in univariate analysis.
Table 4.5: Attack rate and relative risk of leptospirosis due to accidental contact
with rodents
LEPTO- PATIENTS WITH- TOTAL ATTACK RELATIVE
SPIROSIS OUT LEPTOSPI- RATE (%) RISK
PATIENTS ROSIS
Accidental 7 11 18 38.89
contact with
rodents 3.18
No contact 16 115 131 12.21
with rodents
Total 23 126 149
This table implies that those who had accidental contact with rodents had more than thrice
higher risk of leptospirosis infection compared to those who had no contact with rodents.
Additionally, the investigators considered the confidence interval of the relative risk and
the p value of the result, both of which tells the investigators how statistically significant
the observed association was. In this case, the observed confidence interval was 1.5 – 6.7,
p=0.01.
Another exposure was considered – harvesting with uncovered hand lesions;
78
Table 4.6: Attack rate and relative risk of leptospirosis due to harvesting with
open hand wounds
LEPTO- PATIENTS TOTAL ATTACK RELATIVE
SPIROSIS WITHOUT LEP- RATE (%) RISK
PATIENTS TOSPIROSIS
Harvesting 15 34 49 30.61
with open
hand wounds
3.47
Harvesting 9 93 102 8.82
without open
hand wounds
Total 24 127 151
This table implies that those who harvested with open hand wounds had about 3.5 times higher
risk of leptospirosis infection compared to those who harvested without open hand wounds.
Similarly, the investigators considered the Confidence Interval of the relative risk and the p
value of the result, both of which tells the investigators how statistically significant the ob-
served association was. In this case, the observed confidence interval was 1.6 – 7.4, p=0.001.
Finally, eating unwashed strawberries;
Table 4.7: Attack rate and relative risk of leptospirosis due to eating unwashed
strawberries
LEPTO- PATIENTS TOTAL ATTACK RELATIVE

SPIROSIS WITHOUT LEP- RATE (%) RISK
PATIENTS TOSPIROSIS
Eating 23 90 113 20.35
unwashed
strawberries
7.73
Not eating 1 37 38 2.63
unwashed
strawberries
Total 24 127 151
This table implies that those who ate unwashed strawberries had about 7.7 times higher
risk of leptospirosis infection compared to those who did not eat unwashed strawberries.
Similarly, the investigators considered the confidence interval of the relative risk and the
p value of the result, both of which provided the investigators how statistically significant
the observed association was. In this case, the observed confidence interval was 1.1 –
55.4, P=0.01.
In the final multivariable model, only harvesting in the rain with hand lesions remained
a statistically significant risk factor for infection, so that with each working day in the
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ONE HEALTH MANUAL
rain with hand wounds, the odds of acquiring infection was 1.1 (95% CI, 1.04–1.14; P <
0.001). The odds of infection with each day worked in the rain without hand lesions was
not statistically significant (OR, 1.01; 95% CI, 0.9–1.1; P = 0.8). Accidental rodent con-
tact was also independently associated with the infection (OR, 4.8; 95% CI, 1.5–15.9; P =
0.01) in multivariate analysis. Exclusion of suspected cases did not affect the outcome of
multivariate analysis (each working day in the rain with hand wounds: OR, 1.1; 95% CI,
1.05–1.17; P < 0.001; accidental rodent contact: OR, 4.7; 95% CI, 1.04–20.9; P = 0.04).
Days worked in the rain with hand lesions was the strongest predictor for acquisition of
infection in this study. The probable mode of transmission was contact between hand
wounds and water-logged soil contaminated by vole urine or direct contact with voles.
The strawberry pickers rarely wore gloves while working; therefore, scratches and
wounds were common and may have also been present among those case patients who
did not recall having them. Skin wounds have previously been associated with leptospiro-
sis in tropical climates. Despite the strong association between strawberry consumption
and leptospirosis in univariate analysis, the association did not remain in the final mul-
tivariate model, which may be explained by confounding. Wounds were more common
when individuals work longer in the field, and this may also increase the likelihood of
strawberry consumption.
In conclusion, the investigators proposed that leptospirosis may have served as a mod-
el for an endemic disease that is affected by climate change. With the impact of global
warming on health still unpredictable, heightened surveillance for both human and ani-
mal populations is essential for timely interventions. For occupations associated with en-
hanced risk of rodent contact, rodent control may be of some benefit, and lesions should
be covered with waterproof dressings. Gloves should be worn, especially by those with
professions affected by heavy rain. In situations of accidental contact with rodents in the
presence of open wounds, individuals may be advised to receive doxycycline as post ex-
posure prophylactic treatment.
(Source: Desai S, van Treeck U, Lierz M, Espelage W, Zota L, Czerwinski M, Sadkowska-Todys
M, Avdicová M, Reetz J, Luge E, Guerra B. Resurgence of field fever in a temperate country: an
epidemic of leptospirosis among seasonal strawberry harvesters in Germany in 2007. Clinical
Infectious Diseases. 2009 Mar 15;48(6):691-7).
Case Study 3: Case-Control Study
On October 13, 1999, a 15-year-old boy from Kg. Kabidang was admitted to Beaufort
Hospital Sabah Malaysia, for fever, cough and vomiting after swimming in the creek in
Kg. Kebatu (a small local stream). Subsequently until October 21, 1999, a total of 46
males aged 8 to 19 years were admitted to Beaufort Hospital. All had a history of swim-
ming in the creek in Kg. Kebatu. The association between the illness and swimming in
the creek was suspected and the community was immediately warned not to swim in the
creek. An investigation was conducted to determine the source and the cause of the out-
break.
The district of Beaufort is situated in the south western part of Sabah and has a total area
of 1280 square km. It is approximately 90 km from Kota Kinabalu, the capital of Sabah
and is accessible via a good tarred road. Communication within the district is through an
80
expanded road network. The main occupation is farming. The total population was esti-
mated to be 65,000 in 1998. Kg. Kebatu is a village situated about 7 km from Beaufort
town. This village is surrounded mainly by agricultural activity such as cultivation of oil
palm, and rubber, commercial farming of livestock such as chicken, cows and buffaloes.
The creek is situated in Kg. Kebatu. There is a rubber factory located at the upper end of
the creek and the lower end finally drains into the Klias River. The creek is normally shal-
low and flows slowly with a depth of less than half a meter. However, after heavy rainfall,
the depth could reach more than 2 meters. During that time, many children and teenagers
from the nearby villages swim in the creek.
A case was defined as a resident of Kg. Kebatu, Kg. Kabidang, Kg. Parit or Kg. Lajau,
who developed any or combination of the symptoms i.e. fever, vomiting, cough, body
ache or headache and the onset of the illness was from 11 October to 19 October, 1999.
A team consisting of a Medical Officer of Health, a Senior Health Inspector, three Health
Inspectors, a Public Health Nurse and two Public Health Assistants from the Health Office
Beaufort carried out the investigation in the affected areas namely Kg. Kebatu, Kg. Ke-
bidang, Kg. Parit and Kg. Lajau. An active case detection was conducted on October 23
and 24, 1999 by interview and examination of the villagers for the detection of new cases.
Passive Case Detection: The Hospital and health facilities in Beaufort were alerted and in-
structed to admit all the cases that fulfil the case definition to Beaufort Hospital.
A case control study was conducted. Study population was four villages in Beaufort namely
Kg. Kebatu, Kg. Kabidang, Kg. Parit and Kg. Lajau which were selected as the study area.
Approximately 1,000 persons lived in the villages located in these areas. Individuals meet-
ing the case definition were accepted as cases. Whereas controls were defined as a healthy
male individuals aged 8 to 20 years from the affected villagers namely Kg. Kebatu, Kg.
Kebidang, Kg. Parit and Kg. Lajau. The controls were interviewed to determine whether
they had a history of recent swimming in the creek (30th September to 7th October). Labora-
tory Investigation: Paired serum samples were collected (acute- inpatients, convalescent- on
follow up) and sent to University of Malaya Medical Centre, Kuala Lumpur for serological
tests. The serological test used for the detection of leptospira antibodies was the microscop-
ic agglutination test (MAT) using leptospira organisms as the antigen. A titre of ≥ 320 is
taken to be a positive titre for leptospirosis. The diagnosis of current or recent leptospira
infection is based on seroconversion from < 80 to at least 160 or a significant (≥ 4-fold) in-
crease in titre between acute and convalescent-phase sera. Blood samples were sent for rou-
tine analysis and investigations of pyrexia of unknown origin (PUO). Water samples were
analysed for chemicals and leptospira.
A total of 46 persons were admitted to Beaufort Hospital. They were all males, aged 8 to
19 years (mean age: 14.4 years) from Kg. Kebatu (41), Kg. Kebidang (1), and Kg. Lajau
(4). All the 46 persons had a history of swimming in the creek in Kg. Kebatu. Thirty per-
sons (65.2%) had illness that met the definition for case and 16 persons were asymptom-
atic. The 30 cases, aged 10-19 years (mean age: 14.8 years), were from Kg. Kebatu (26),
Kg. Kabidang (1), and Kg. Lajau (3). The symptoms included fever, vomiting, body ache,
giddiness, headache, chest pain and cough. The onset of the illness was from 11th Octo-
ber to 19th October 1999 and the probable period of exposure was around the first week
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ONE HEALTH MANUAL
of October, 1999. A 15-year-old boy died (17th October 1999) from haemorrhagic shock
secondary to pulmonary haemorrhage. A clinical diagnosis of leptospirosis was made for
this fatal case. The rest of the cases responded well to antibiotic treatment (doxycycline or
amoxycillin or IV C-Penicillin). A total of 104 healthy males aged 8 to 20 years old (mean
age: 13.6 years) from the affected area namely Kg. Kebatu (76), Kg. Kabidang (12), Kg.
Parit (10) and Kg. Lajau (6) were recruited as controls and included in the analysis, the χ2
was 50.8 and p-values was less than 0.0001.
A total of 44 paired sera samples were sent for microscopic agglutination test (MAT) (28
cases and 16 asymptomatic-patients). Of the total 44 paired sera, 5 paired sera showed
seroconversion (cases=5), 3 paired sera had > 4-fold rise in titre (cases=0) and 18 paired
sera were positive at titre of ≥ 320 for both samples (cases=13). A total of 18 paired sera
were negative (case-patients=10). A total of 22 cases also examined for LeptoIgM (IgM
capture ELISA for leptospirosis using a commercial test from Australia); of these, 16 were
positive. One case-patient submitted only a convalescent-phase serum specimen, which
was positive by both MAT and LeptoIgM. Serum specimens had not been obtained from
the boy who had died from haemorrhagic shock. Analysis of additional blood specimens
documented leucocytosis in five persons (cases=4), thrombocytopaenia in one case-pa-
tient and urine positive for bile in one case patient. Liver function tests were normal. Tests
for malaria, typhoid, scrub typhus, dengue fever, and Hantavirus were negative. Blood
and urine cultures yielded no growth. The water samples sent to Queen Elizabeth Hospital
were negative for leptospira by dark field microscopy. The chemical analysis of the water
samples was negative for pesticide, herbicide, cyanide and hydrogen sulfide.
The epidemic curve suggested a common source outbreak, and the spot map showed the
cases to be spread across Kg. Kebatu (41), Kg. Kebidang (1), and Kg. Lajau. Hypothe-
sis-generating interviews resulted Kg Kebatu creek as the candidate source. In a situation
like this a case-control design is a much more efficient option. The investigators identified
as many cases as possible and they selected a sample of 104 non-diseased people as a
comparison group (the controls). In this case, the “controls” were non-diseased people
who were matched to the cases with respect to age, gender, and neighbourhood of resi-
dence. Investigators then ascertained the prior exposures of subjects in each group, focus-
ing on swimming and other possibly relevant contact with the creek during the past two
weeks.
When using a case-control strategy for sampling, it is not possible to calculate the inci-
dence (attack rate) in exposed and non-exposed subjects, because the denominators of the
exposure groups are unknown. However, one can calculate the odds of disease in exposed
and non-exposed subjects, and these can be expressed as an odds ratio, which is a good
approximation of a risk ratio in a situation like this, i.e., when the outcome is rare. An
odds ratio can be computed for each of the possible sources.
82
Consider the following example:
Table 4.8: Distribution of cases and controls with swimming exposure

SWIMMING CASES CONTROLS TOTAL
Yes 29 26 55
No 1 78 79
30 104 134
*Actual results slightly modified
Given these results, the odds that someone who swam at the creek was a case were 29 / 1,
while the odds that someone who swam at the creek did not become a case were 26 / 78.
These odds are quite different, and the odds ratio is about 87. The odds ratio can be inter-
preted the same way as a relative risk.
Odds Ratio = (29/1) / (26/78) = 87.08
This certainly provides a compelling evidence to suggest an association between swim-

ming and the illness, meaning that swimming at the creek was a risk factor for leptospiro-
sis, but, as we did with the risk ratio, we could compute a 95% confidence interval for the
odds ratio, and we could also compute a p value. In this case the 95% confidence interval
is 81.32 to 93.47, and p<0.0001.
The case-control study found that the illness was associated with swimming in the creek
in Kg. Kebatu (p<0.0001). The water in the creek could have been contaminated by in-
fected animals from the affected areas (cattle, pigs, dogs, rodents, and wild animals). The
occurrence of flooding might facilitate the spread of the organism because, as water sat-
urates the environment, leptospira present in soil could pass directly into the creek. The
patients acquired the infection through exposure to contaminated water in the creek while
swimming. Leptospira might enter the body of the patients by penetration through cuts or
abraded skin, mucous membranes, and conjunctivae. The flooding and stagnation of the
creek following the heavy rainfall could have contributed to the timing of the outbreak.
In case-control studies, one of the most difficult decisions is how to select the controls.
Ideally they should be non-diseased people who come from the same source population as
the cases, and, aside from their outcome status, they should be comparable to the cases in
order to avoid selection bias. Note that in this case-control study the controls were select-
ed in a way to ensure that they were comparable with respect to age and gender and lived
in similar neighbourhoods.
(Source: Koay, T. K., Nirmal, S., Noitie, L., & Tan, E. (2004). An epidemiological investiga-
tion of an outbreak of leptospirosis associated with swimming, Beaufort, Sabah. Med J Malay-
sia, 59(4), 5.)
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ONE HEALTH MANUAL
BIBLIOGRAPHY
BREUER, T., BENKEL, D.H., SHAPIRO, R.L., HALL, W.N., WINNETT, M.M., LINN,
M.J., NEIMANN, J., BARRETT, T.J., DIETRICH, S., DOWNES, F.P. AND TONEY,
D.M. 2001. A multistate outbreak of Escherichia coli O157: H7 infections linked to alfalfa
sprouts grown from contaminated seeds. Emerging infectious diseases, 7(6), 977.
CDC 2016. Eight Multistate Outbreaks of Human Salmonella Infections Linked to Live
Poultry in Backyard Flocks (Final Update) [Online]. Atlanta, USA: US Center for Disease
Control and Prevention. Available: http://www.cdc.gov/salmonella/live-poultry-05-16/in-
dex.html [Accessed August 23 2016].
DESAI, S., VAN TREECK, U., LIERZ, M., ESPELAGE, W., ZOTA, L., CZERWINSKI,
M., SADKOWSKA-TODYS, M., AVDICOVÁ, M., REETZ, J., LUGE, E. AND GUER-
RA, B., 2009. Resurgence of field fever in a temperate country: an epidemic of lepto-
spirosis among seasonal strawberry harvesters in Germany in 2007. Clinical Infectious
Diseases, 48(6), 691-697.
FRASER, D. W., TSAI, T.R., ORENSTEIN, W., PARKIN, W.E., BEECHAM, H.J.,
SHARRAR, R.G., HARRIS, J., MALLISON, G.F., MARTIN, S.M., MCDADE, J.E.
AND SHEPARD, C.C., 1977. Legionnaires’ disease: description of an epidemic of pneu-
monia New England Journal of Medicine, 297(22), 1189-1197.
KOAY, T. K., NIRMAL, S., NOITIE, L. AND TAN, E. 2004. An epidemiological investi-
gation of an outbreak of leptospirosis associated with swimming, Beaufort, Sabah. Med J
Malaysia, 59(4), 5.
TOROK, M. 2014. FOCUS on Field Epidemiology Hypothesis Generation During Out-

breaks [Online]. North Carolina, USA: North Carolina Center for Public Health Prepared-
ness - The North Carolina Institute for Public Health. Available: http://sph.unc.edu/nciph/
focus/ [Accessed August 23 2016].
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CHAPTER FIVE
IMPLEMENTATION OF
CONTROL MEASURES
Dr. Hidayatul Fathi Othman; Dr. Zainol Pawanchee;

Dr. Yahasmida Yaacob; Dr Sharifah Salmah Syed Hussain;
Dr. Surajudeen Abiola Abdul Rahman;
Dr Siti Fatimah Kader Maideen
ONE HEALTH MANUAL
5.0 Introduction
Disease control programmes are commonly initiated with the aim of ultimate eradication
of agents at a compartment level, zone and finally the country. However, for some diseases,
eradication may not be feasible, so options for sustained mitigation of disease is needed.
5.1 Rationale for Implementation of Disease Control

It is essential to describe the programme objectives which may include simple mitiga-
tion of disease impacts to progressive control or eradication of the particular disease.
Figure 5.1: Steps for establishing a disease control programme

Source: OIE- Guidelines for animal disease control, 2014.
The justification for the disease control programme would include the following:
1. Situation of the zoonotic diseases

2. Impact of the zoonotic diseases which includes animals, public health, food
safety, food security, biodiversity and socioeconomic impact and how severe
these impacts were affecting the stakeholders
3. Participation of stakeholders and their level of interest
Zoonotic diseases may be divided into groups which may pose different levels of threat
which will require different levels of responses. The levels below are suggested diseases
and threats.
Group A:
Group A is a group of diseases that pose highest threat to the security and safety of the
public. The diseases include those that are easily transmissible from person to person; or
those that cause high death rates, and which threaten the health of the public, causes fear
among the public and disruption of social and economic activities. Examples of Zoonotic
diseases under group A include anthrax, plague, botulism, viral haemorrhagic fever such
as Ebola, SARS, Nipah, infection with avian influenza viruses, rabies etc.
Group B
These are Zoonotic diseases caused by pathogens that pose a relatively lower threat than
group A. They include those diseases that are moderately infectious, which causes moder-
ate illness and death. Nevertheless, improved diagnostic capacity and surveillance are
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IMPLEMENTATION OF CONTROL MEASURES
required for adequate control. They include Brucellosis, food and waterborne pathogens
(such as E.coli, Salmonella spp, Cryptosporidium parvum), Japanese encephalitis virus,
leptospirosis etc.
Group C
Group C includes pathogens with the lowest threat to the security and safety of the public.
They include Hendra viruses, hanta viruses, MERS-COV etc.
Note: These lists are non-exhaustive and subject to change.

Source: modified from NIAID, National Institute for Allergy and Infectious Diseases: Emerging
Infectious Diseases/Pathogens, January 2016
The urgency in controlling a disease outbreak will depend on the many factors, including
the groups stated above. The other factors that may be considered are as in Table 5.1.
Table 5.1: Factors in considering implementation of disease outbreak control.
Source: Adapted from OIE- Guidelines for animal disease control, May 2014.
5.2 General Concept of Disease Control

Control means the reduction of disease prevalence in the community, although transmis-
sion still occurs but it is no longer a major public health problem. Elimination is when the
pathogen ceases to exist in the human host whereas eradication is the complete removals
of the pathogenic organism in all of its forms, from both the human and environment res-
ervoirs.
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ONE HEALTH MANUAL
The US Centre for Disease Control (2006) highlighted the strategies for infectious diseas-
es to include applying appropriate control methods which include elimination of reservoir,
interruption of transmission, protection of susceptible host, notification and legislation,
and surveillance.
The 3 components of eradication and control include
• Communicable aspect of disease control i.e. elimination of organism by the use of

drugs
• Non-communicable aspect of disease control i.e. deformity care and prevention
through physiotherapy and surgery
• Eradication of socio-economic problems i.e. rehabilitation and removal of social
stigma
5.3 Strategies of zoonotic disease control
The strategies may include breaking the chain of transmission using one or more of the
following elements:
1. Disease notification - All occurrences of animal diseases are to be reported to

the Director of the State Veterinary Services through Veterinary Health Division
Chief and ultimately to the Director General of Veterinary Services through An-
imal Disease Information Centre (ADIC). The incidence of the disease includes:
a) any of the 125 notifiable diseases (Please refer to APTVM: Pengurusan
Indeks Penyakit Haiwan). Of these, 14 are zoonotic diseases of public
health importance. They include Bovine tuberculosis, brucellosis, sal-
monellosis, rabies, Nipah virus, Hanta virus, bovine spongiform enceph-
alopathy, leptospirosis, influenza, filariasis, anthrax, Rift Valley fever,
Japanese encephalitis and Q fever.
b) any animal deaths in excess of the norm (Please refer to APTVM: Pen-
gurusan Indeks Penyakit Haiwan); or
c) all infectious disease symptoms related to respiratory, nervous system,
anorexia, deterioration of the level of farm production, the vesicular le-
sions, diarrhoea and abortion.
For the common level of disease occurrence, the Head of Epidemiology Section will car-
ry out disease investigation, but for disease considered as a big threat, action be taken by
Early Warning Team in headquarters where they will decide to mobilize the Rapid Ac-
tion Team (RAT). For confirmation, the samples sent by the RAT to Regional Laboratory
should be processed immediately and lab results must be sent to the Early Warning Team
as soon as the results are obtained. Zoonotic diseases such as rabies, brucellosis, avian
influenza etc. should also be notified to District Health Office under the Prevention and
Control of Infectious Disease Act 1988 (PCID).
For human cases, notifications can be made either by phone, fax, despatch or eNotifikasi.
eNotifikasi was launched on 2nd of January 2011 to replace eNotis/CDCIS. eNotifikasi is
available at the following website http://enotifikasi.moh.gov.my/Login.aspx. eNotifikasi
88
is used for specific diseases (eDengue, National Aids Registry, MyTB, e-measles). The
users for this system are the Assistant Medical Record Officer (AMRO), Assistant Envi-
ronmental Health Officer (PPKP) at the district / state Level and Medical Officer, District
Health Officer, Epidemiological Health Officer and Officer at the Ministry Level.
As shown in Figure 5.2, when an Environmental Health Officer is notified via phone,
email (e-Notifikasi) or notification form regarding a communicable disease, he/she first
stamps and registers the time and date the forms were received and passes it on to the
assistant environmental health officer who registers it into e-notifikasi and keeps a record
of the form in the investigation file under communicable diseases. The health officer then
prepares the investigation forms and equipment’s required for the specific type of disease.
He/she is also responsible for sending a report to the state health department. He and the
team may visit the patient’s house and implement the necessary prevention and control
methods to stop further spread of the disease amongst the contacts. He/she then records
and files the investigational activities carried out. He/she also analyses the data and again
sends a copy of the final report to the state health department.
Receive notification by phone/ fax/ e-notice/ notification form
Stamp the date and time received on the notification form
Pass the form to District Health Office/ Assistant Environmental Health Officer
Register onto e-notice
Keep the form in the Investigation of communicable disease file

Prepare investigation form and equipment according to the type of disease
Obtain detailed information
Record data into case register
Send preliminary report to State Health
Inform state health department
Control & Preventive Measures
Record and file up the activities carried out
File the case investigation form
Checking, Analysis and Signature by District Health Office
Send the report to the State Health
Keep a copy of report in the file

Figure 5.2: Notification flow chart of communicable diseases under Prevention and
Control of Communicable Diseases Act 1988
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ONE HEALTH MANUAL
Notification of communicable diseases to the CDC unit in the district health office by the
health care personnel is mandatory. The list of diseases in Table 5.2 is mandatory to be
notified within the mentioned time frame. Other diseases which require notification in-
clude Brucellosis, Melioidosis and Chikungunya.
Table 5.2: List of diseases that must be notified to nearest health office
Note: The notification of these diseases is subject to change from time to time.
2. Elimination of reservoir – in cases where humans are the reservoir, all patients
and carriers are found and treated, and for zoonosis, the suspected hosts are
eliminated.
3. Early Diagnosis & Treatment – will help shorten the course of the illness and
the period of communicability
4. Isolation and Quarantine – isolation is the separation of infected persons or
animals during the period of communicability to prevent direct or indirect trans-
mission of infectious agent whereas quarantine is the limitation of the freedom
of movement of contacts*, be it persons or animals, which have been exposed a
communicable disease. The process of quarantine is usually for a period of time
which is not longer than the longest usual incubation period.
*Contact is a person or animal that has been in contact with an infected
person or animal or a contaminated environment.
5. Personal Hygiene – health education and promotion on personal hygiene is
imparted to limit the spread of infectious diseases especially those transmitted
by direct contact.
6. Cleaning – the process of removing infectious agents and organic matters from
surfaces on which infectious agent may find favourable conditions for survival
or multiply is done in certain cases.
90
7. Disinfection – is the process of killing infectious agents outside the body.

8. Interruption of transmission – is the process of changing essential components
of man’s environment to prevent or break transmission of the infectious agents
9. Control of food-borne diseases – this is achieved by ensuring proper hand
washing techniques, adequate cooking, refrigeration, removal of contaminated
food etc.
10. Control of water-borne diseases – this is done by chlorination of water
11. Control of vector-borne diseases – this is done by the destruction of specific
vectors and their breeding places.
12. Protection to susceptible host – protection of the susceptible host can be done
by immunization, both active and passive. Active immunity is the process of ex-
posing the body to an antigen in order to generate an adaptive immune response.
This response may take days/weeks to develop but it is usually long lasting or
even lifelong. Passive immunity, on the other hand, is the process of providing
IgG antibodies to protect against infection. It gives immediate, but short-lived
protection usually several weeks to 3 or 4 months at the most. The immunisation
programmes of the Ministry of Health include childhood immunisation and im-
munisation to high risk groups.
13. Health Education – is given to individuals and groups of people learn to pro-
mote, maintain or restore health.
Figure 5.3: summarizes the different control measures that can be implemented to break
the chain of transmission at different points.
Figure 5.3: The chain of transmission of infectious diseases and ways of breaking it
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ONE HEALTH MANUAL
Figure 5.4 illustrates the example of breaking the chain of transmission of leptospirosis.
Hygiene
Figure 5.4: Examples of breaking the chain of infection for leptospirosis
5.4 Activation of outbreak Operation room

For all infectious disease outbreak, an outbreak operation room will be activated at the
district and higher levels. The operation team will involve multidisciplinary personnel
which comprise of public health specialist, epidemiologist, environmental health officer,
microbiologist, virologist, veterinarian and enforcement team such as fire brigade, police
and etc. (depending on the particular disease).
5.4.1 Control strategies for animals

The team is responsible for implementing the control activities listed below during an out-
break or crisis:
1. Quarantine
2. Destroy and/or vaccination (whichever applicable)
3. Disinfection/decontamination
4. Culling/disposal
5. Enforcement
6. Surveillance
7. Public health education
1) Quarantine
Quarantine of animals and birds are mandatory for the purpose of monitoring. Dis-
ease control is done in the infected area, control area and elimination area. Figure 5.6
illustrates the procedure for quarantine of infected animals. For example, suspected
rabid dogs must be quarantined in District Veterinary Services Centre (PPVD) and
monitored for the sign and symptoms of the disease for duration of 10 days. Blood
test should be taken for confirmation and if found positive, they should be culled.
92
Figure 5.5: Flow chart of emergency response during disease outbreak

Source: Arahan Prosedur Tetap Veterinar Malaysia, 2011. Pengurusan krisis penyakit haiwan.
APTVM 24(a): 1/2011
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ONE HEALTH MANUAL
Figure 5.6: Flow chart of quarantine of a diseased animal

Source: Arahan Prosedur Tetap Veterinar Malaysia, 2010. Kuarantin haiwan berpenyakit.
APTVM 22(a): 1/2010
94
2) Destroy
Destroy contaminated materials of animal house, equipment or anything that is
in contact with the infected animals or birds.
3) Culling/ disposal
Cooperation from the farmers is crucial to facilitate the process of disposal and
the operations of animal culling. The team decides on the appropriate methods
and location of culling. The team will require the cooperation from local agen-
cies and Public Works Department, Irrigation and Drainage Department, Envi-
ronmental Department, Land and Mines Offices, District Offices and Local Mu-
nicipals. Based on the protocol of veterinary Malaysia, infected animals or birds
and those that are at risk of infection must to be culled either individually or
as collectively either by shooting, gas suffocation (such as CO2) or euthanasia.
For example, in the Nipah virus outbreak infection, the reservoir or source of in-
fection was culled. Animal carcasses were then disposed appropriately either by
burying or incineration. In burying method, lime is sprinkled on the first layer of
soil to reduce the risk of contracting live virus. Then, the carcasses will be bur-
ied and sprinkled again with another layer of lime and followed by another thick
layer of soil. The carcasses can also be incinerated and the area decontaminated
or disinfected.
4) Treatment
During an outbreak of leptospirosis, all the infected animals are treated either
with penicillin or doxycycline while the exposed animals are given prophylaxis
with the same drugs. The following control measures are applicable in the con-
trol of all zoonotic diseases outbreak.
5) Vaccination
Where the zoonotic disease is a vaccine-preventable disease, vaccination is given
to animals either by injection (subcutaneous or Intra Muscular), oral, eye drops
and nasal spray.
6) Disinfection/decontamination
All organic materials located on the floor, wall, coop/cage/shed and other equip-
ment is cleaned before the disinfectant solution is sprayed to the areas involved.
The disinfection process includes vehicle, premise and equipment. The premise
is cleaned with suitable disinfectant. Faeces that cannot be buried or incinerated
is sprinkled with lime and the premise is closed for 60 days. All the equipment
used for the disinfection process should be disinfected too. The team involved in
the decontamination operation should comply with the instruction of disinfecting
clothes, equipment and vehicles used.
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ONE HEALTH MANUAL
7) Enforcement
The movement of vehicles is restricted or limited to the outbreak or crisis area
to prevent the spread of the disease. Transportation carrying food to the Surveil-
lance Zone must be controlled thoroughly. The enforcement team made up of
the DVS Enforcement Officer with the help of the Police Department who are in
charge of seizing infected farms, quarantine of Infected Zone, Suspected Zone as
well as Surveillance Zone. They are responsible to set up roadblocks to ensure
no animals or high-risk materials from leaving the risk zone until permitted.
8) Surveillance
There are 2 types of surveillance - active surveillance & passive surveillance.
Scheduled or planned surveillance by DVS are considered as Active surveil-
lance. Examples of active surveillance are:
i. Yearly national plan surveillance
ii. Disease index
iii. Surveillance during outbreak.
For every disease, there is a planned annual surveillance program scheduled by
the DVS in which a specified sample is taken from each of the premise based on
the prevalence of the disease and the total number of premises. Under disease
index, for example of Brucellosis, serum from the cattle which is more than 4
months old is tested with RBPT/ELISA. If found positive, the infected animal
is culled and the herd is considered as positive and sampling is repeated every 4
months until the herd is found negative. During an outbreak, surveillance must
be done in 100% of the cattle in the herd. For infected cattle, they must be iso-
lated and treated. For infected goats, they are depopulated by stamping process.
Passive surveillance is done throughout the year by the veterinarian, the officer
in-charge and industry players. On-going monitoring is done by the personnel
based on clinical sign, death or morbidity whereby the occurrence is more than
the usual. For the case of Brucellosis, passive surveillance is based on the move-
ment of the cattle and clinical case. For those cattle that are transported for the
purpose of breeding or slaughtering, their serum is tested with RBPT/ELISA
unless the cattle are from the disease-free group. For the cattle that shows the
symptoms of Brucella abortus, serum samples from the aborted materials is test-
ed with RBPT/ELISA for the purpose of isolation of the bacteria.
9) Public health education

The health education campaign is conducted to increase the awareness of the
public on certain diseases. The campaign can be done via electronic media,
printed media, briefing or seminar, through counselling process, short message
service (SMS) or other methods such as in the websites or blogs, etc. During
an outbreak of zoonotic disease, every single house in the infected zone will be
96
visited and the occupants will be informed and educated about the disease. Rou-
tinely, the state veterinary services will conduct public awareness campaigns on
all the diseases from time to time in terms of identification of the sign and symp-
toms of the diseases and the preventive measures.
5.4.2 Control strategies in human
Prevention and control measures for humans are directed towards source of infection,
mode of transmission and susceptible population. Strategies that can be taken at source or
reservoir of infection include isolation, quarantine, cleaning, disinfection and treatment.
Whereas strategies to control the mode of transmission include disinfestation, provision
of safe and adequate water supply, proper sewage and waste disposal and food sanitation.
While the strategies to prevent the susceptible population from acquiring the disease in-
clude health education, personal hygiene, chemoprophylaxis and vaccination.
The specific nature and urgency with which control measures are implemented in the case
of an infected human depends on a host of factors which includes communicability of
the disease, mortality and morbidity of the disease and practicality of chosen intervention
measures within the context of the outbreak. For example, in the case of influenza, the
infected person should be isolated especially during the period of communicability until
they are fully recovered. Drastic measures such as isolation and quarantine of cases may
be required for potentially highly fatal diseases like SARS and Ebola. Cleaning via proper
hand washing is done to avoid the transmission of the virus to the others. And it is essen-
tial that the infected individuals be offered prompt treatment.
For controlling the mode of transmission, example in the case of Malaria, disinfestation
by fumigation should be done. To avoid food-borne diseases such as Salmonellosis, food
sanitation and proper food handling is the utmost practice that should be prioritized. Ade-
quate cleaning and disinfection of contaminated surfaces, tools and equipment should also
be done. Contaminated faecal materials and secretions should be adequately cleaned and
properly disposed by flushing through a water system connected to a covered septic tank
to avoid the spread of the virus.
To protect the susceptible population from acquiring the disease, the public should be ed-
ucated about the disease, personal hygiene and proper hand washing techniques. The im-
portance of proper hand washing techniques should be emphasized. Where the disease
is vaccine-preventable, protective vaccination of exposed humans should be initiated,
even before human cases are reported. Additionally, chemoprophylaxis, where applicable,
should be provided to human contacts as soon as possible. For example, those who have
high exposure to rabies, such as veterinarians, animal handlers, laboratory workers etc.
should be given three doses of rabies vaccine. In case of deaths, packaging, transfer and
burial of the bodies should be supervised under controlled conditions and the wearing of
protective equipment, such as hazardous material suit (Hazmat suit).
More importantly, in all cases of zoonotic disease outbreaks, extensive and immediate
public education should be initiated to keep the public informed of the threat and how to
prevent and control the situation, while active surveillance among humans is intensified.
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ONE HEALTH MANUAL
5.5 The aim of control measures (modified from Guidelines for the Investi-
gation and Control of Disease Outbreaks, 2011)
Three areas are targeted as control measures during an outbreak: the source of outbreak,
contaminated vehicles involved during transmission and susceptible humans. The choice
of control measure within these three areas is dictated by factors such as whether the out-
break source is known, whether a suspected vehicle has been identified and whether a
vaccine or prophylactic treatment is available for susceptible humans.
5.5.1 Control measures pertaining to an outbreak

5.5.1.1 Source of outbreaks related to animal contact
These animals at risk should be removed from contact by isolating and/or immunizing
them. In exceptional cases animal carriers may be destroyed.
5.5.1.2 Source of outbreaks related to human
Individuals and carriers are to be treated, imposed temporary restrictions or exclusion; or
restriction of activities such as restrictions on people handling food or showing signs of
gastroenteritis; isolation of infected patients and managing in-house patients infected with
infectious and contagious diseases (e.g. MRSA); quarantine those arriving into the coun-
try with symptoms (viral haemorrhagic fever) or those with history of close contacts of a
confirmed infectious case; educating and advising individuals.
5.5.2 Control measures pertaining to contaminated vehicles and vectors

5.5.2.1 Source of outbreaks related to contaminated food or water
Includes removing or recalling of products that are contaminated, initiating treatment, steriliza-
tion or pasteurization of materials that are contaminated.
5.5.2.2 Source of outbreaks related to vectors
The use of insecticides, installing of traps, removing breeding habitats and management
of solid waste.
5.5.3 Control measures pertaining to susceptible humans

5.5.3.1 Source of outbreaks related to food, water or environmental causes
Educating and creating awareness in order to change behaviour associated with food
preparation and hygiene and implementation of food safety measures; providing instruc-
tions to conduct sterilization or treating contaminated materials or equipment; educating
and creating awareness to reduce contact with vectors and promoting the use of bed net-
tings, long-sleeved shirts and the use of insect repellents.
5.5.3.2 Source of outbreaks related to human
Treating individuals with chemoprophylaxis; providing and administration of vaccines
and immunoglobulin; providing advice and awareness on the use of physical barriers; im-
proving resistance towards infection via proper nutrition.
98
BIBLIOGRAPHY
MOAAI 2008. Protokol veterinar Malaysia, Brucellosis (Brucella abortus). PVM 1(4):
1/2008. Putrajaya, Malaysia: Ministry of Agriculture and Agro-based Industry.
MOAAI 2010. Arahan Prosedur Tetap Veterinar Malaysia, Kempen kesedaran awam.
APTVM 21(a):1/2010. Putrajaya, Malaysia: Ministry of Agriculture and Agro-based In-
dustry.
MOAAI 2010. Arahan Prosedur Tetap Veterinar Malaysia, Kuarantin haiwan berpenyakit.
APTVM 22(a): 1/2010. Putrajaya, Malaysia: Ministry of Agriculture and Agro-based In-
dustry.
MOAAI 2010. Arahan Prosedur Tetap Veterinar Malaysia, Penghapusan. APTVM 22(e):
MOAAI 2010. Arahan Prosedur Tetap Veterinar Malaysia, Pengurusan Indeks peny-
kit haiwan. APTVM 16(a)(b): 2/2010. Putrajaya, Malaysia: MInistry of Agriculture and
Agro-based Industry.
MOAAI 2010. Arahan Prosedur Tetap Veterinar Malaysia, Vaksinasi. APTVM 22(b):
MOAAI 2011. Arahan Prosedur Tetap Veterinar Malaysia, Disinfeksi. APTVM 22(d):
MOAAI 2011. Arahan Prosedur Tetap Veterinar Malaysia, Pengurusan krisis penyakit
haiwan. APTVM 24(a): 1/2011. Putrajaya, Malaysia: Ministry of Agriculture and Agro-
based Industry.
MOAAI 2011. Arahan Prosedur Tetap Veterinar Malaysia, Survelan Untuk Penyakit
Haiwan. APTVM 22(g): 1/2011. Putrajaya, Malaysia: Ministry of Agriculture and Agro-
based Industry.
MOAAI 2011. Protokol veterinar Malaysia, Penyakit rabies. PVM 1(17): 1/2011 Putra-
jaya, Malaysia: Ministry of Agriculture and Agro-based Industry.
MOH 2003. Infectious Disease Outbreak, Rapid Response Manual. Putrajaya, Malaysia:
Ministry of Health Malaysia.
NIAID 2016. NIAID Emerging Infectious Diseases/Pathogens [Online]. USA: NAtion-
al Institute of Allergy and Infectious Diseases. Available: https://www.niaid.nih.gov/re-
search/emerging-infectious-diseases-pathogens [Accessed August 23 2016].
OIE 2014. Guidelines for Animal Disease Control [Online]. France: World Organization
for Animal Health. Available: http://www.oie.int/fileadmin/Home/eng/Our_scientific_ex-
pertise/docs/pdf/A_Guidelines_for_Animal_Disease_Control_final.pdf [Accessed August
23 2016].
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CHAPTER SIX
COMMUNICATION
DURING OUTBREAK
INVESTIGATIONS
Dr. Moniza Waheed, Associate Professor Tengku Hanidza Tengku Ismail,

Dr. Mohd Mokrish Md. Ajat, Dr Shaharom Noraziah Che Mat Din
ONE HEALTH MANUAL
6.0 Introduction
This chapter of the manual will provide a guide to personnel involved in matters pertain-
ing to communication when handling an outbreak. Effective interagency communication is
important before, during and after the identification outbreaks. The guidelines are designed
to minimize social and economic disruption. In other words, the steps provided are aimed
at preventing public panic outburst and/or anxiety due to lack or poor communication. It is
also hoped to prevent drastic decline in businesses, tourism, farming and all other related
activities.
6.1 Principles of Communication

In order to ensure effective communication during times of an outbreak, there are several
principles of communication that must be upheld (Parts of the following principles are
similar to those listed by WHO (2005).
• To Announce Early
It is crucial to alert the public early, especially to those who are directly af-
fected. The announcement should include information on how to minimize the
spread of the infectious disease. Informing the public early will prevent ru-
mours, speculations and misinformation to be circulated by word of mouth or
via social media platforms. On the other hand, the longer officials withhold
information, the harder it will seem to make the announcement. Usually, late
announcements will erode trust in the ability of local authorities to manage the
outbreak. Moreover, credibility of local authorities will decrease drastically if
the information is revealed by an outside source.
• To be Transparent
Respective officials should be transparent with plans and managements in
handling outbreaks. Maintaining the public’s trust throughout an outbreak re-
quires ongoing transparency, including timely and complete information of a
real or potential risk and its management. As new developments occur over
the course of an outbreak they should be communicated proactively. Transpar-
ency should characterize the relationship between the outbreak team leaders,
the public and partners as it promotes improved information gathering, risk
assessment and decision-making processes associated with outbreak control.
• To Listen
It is essential to listen and understand the public’s perception on risks relat-
ed to outbreak diseases because the perception of risk may differ between ex-
perts and the public. Once the baseline of the public’s perception on risk has
been obtained, it will be easier to tailor information and decide on methods
of communication that will be widely accepted. This will enable the required
behaviour changes necessary to protect health and curb economic disruption
(refer to section 6.4 on WHO’s Outbreak Communication Information Gather-
ing Template).
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COMMUNICATION DURING OUTBREAK INVESTIGATIONS
• To Plan
Public communication during an outbreak represents an enormous challenge
for any public health authority and therefore the danger lies in planning some-
thing that is theoretically sound, but is impractical when it comes to execu-
tion. Therefore, planning must be sketched out clearly and concisely to ensure
that they can be translated into action. Plans can be shaped from the lessons
learnt from previous outbreaks and through regular crisis simulation activities.
• To Build Trust
When the abovementioned principles are upheld, then trust will be cultivated
towards the authorities handling the outbreak. People are known to comply
with the requests of those they trust compared to those they distrust. There-
fore, the increase of trust will enable better behavioural change which is need-
ed in order to keep an outbreak under control.
6.2 Parties Involved
It is inevitable for many parties to be involved when communicating in times of crisis (lo-
cal leaders, outbreak team, Ministry of Health, Ministry of Primary Industries, Emerging
disease surveillance and response team (ESR), other Public Health Services (PHSs), the
public, the media, etc.. The challenge is to get members of these parties communicating
with one another. Considering this challenge, the outbreak team plays a vital role during an
outbreak. Members of this team will employ risk communication, which is a tool for bridg-
ing the gap between laypeople and experts (Guidelines for the Investigation and Control of
Disease Outbreaks, 2012).
The outbreak team needs to ensure that communication experts/strategists who are located
within the abovementioned parties are properly informed because they need to achieve two
main aims by utilizing the available information; first, to increase visibility in order to get
the message across clearly to the public and second, to ensure that the information they dis-
seminate to the public is legitimate.
The communication of the outbreak team should address the following areas: 1) To ensure
effective communication within the outbreak team. 2) To ensure effective communication
with and between the Ministry of Health, the Ministry for Primary Industries, Emerging
disease surveillance and response team (ESR), other Public Health Services (PHSs) and key
government agencies. 3) To ensure effective communication of the spokesperson with the
public, either directly or through the media, and 4) to ensure effective communication with
other agencies involved in the outbreak, such as local authorities, industry groups, local
hospitals and local primary health care organizations.
It is important to note that effective communication may extend beyond the parties stated
here (depending on the nature and/or severity of the outbreak). Although the term “effec-
tive communication” is used repeatedly in this chapter, there is a certain level of subjectivi-
ty that comes with this term. One of the most common understanding of communication, in
general, is when there is shared meaning between the source and the receiver. Therefore, it
can be assumed that effective communication is when there is a smooth transaction of infor-
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ONE HEALTH MANUAL
mation which results in common understanding between the source and receiver.
6.2.1 Leader(s) of the Outbreak Team(s)

It is important for a leader to be elected from within the outbreak team. The leader has sever-
al key roles to fulfil (even before the occurrence of an outbreak): First, to designate responsi-
bilities to members of the outbreak team. This means the leader must designate the person(s)
in charge for media relations, for event management, etc. Second, the leader must organize
and chair team meetings. Leaders from subcommittees of other parties must attend the team
meetings to ensure effective communication with the abovementioned parties. Third, the
leader must keep all records of communication between the abovementioned parties (e-mail,
phone, fax). Finally, the leader must communicate timely information to the spokesperson of
the Ministry of Health (MOH) and the Department of Veterinary Services (DVS).
6.2.2 Spokesperson and the Media

Ideally a joint statement should be conducted by the MOH and the DVS spokespersons
but at present unlike many other countries, the spokesperson who declares an outbreak is
not chosen/selected/elected. The spokesperson from MOH is the Minister of Health, while
the spokesperson for DVS is the Director General or the Chief Ministers of individual
states (depending on the state where the outbreak occurs). It is vital for the spokespersons
to communicate the information given by the leaders of outbreak teams clearly and con-
cisely to the media, who will then air the information to the public. When communicating
with the media, the spokespersons face the challenge of communicating the information
on outbreaks in a manner that can be understood by members of the media as well as the
public at large without oversimplifying the vital details.
MOH and DVS must establish a good relationship with the media at all times. Waiting to
contact journalists only once an outbreak has occurred is too late. Once an outbreak has
occurred, the spokesperson(s) should be the only ones speaking (and answering questions
from the media). This will minimize confusion and miscommunication.
The media is responsible for disseminating vital information to the public. It is vital to create
an informed public in order for them to be protect themselves (Blumberg, 2001). Therefore,
MOH and DVS must provide vital information concerning infectious diseases on a regular
and frequent basis. This can prevent information vacuums that may be filled by others.
When communicating with the media, the spokesperson must practice the following:
1. To acknowledge the uncertainty of circumstances caused by the outbreak.
2. To not over-reassure members of the media.
3. To know what actual information should and should not be revealed.
4. To include humanistic elements (e.g. touching on the importance of human lives)
in responses to the journalists because emotional elements contribute strongly to
the trustworthiness of officials.
5. To avoid using words such as “irrational”, “panic” in messages.
6. To tolerate relatively harmless early over-reactions. It is also important to note
the demographics of those affected by the outbreak. Although issuing a press
statement that is prepared for print media is standard practice, the crisis manage-
ment team should also consider making radio (community radio stations) and
104
local television channel announcements to reach rural residences.
6.3 Information gathering in preparation for an outbreak

Information on the population in high risk areas and/ or among high risk populations must
be conducted before the problem of an outbreak occurs. This will ease the process of tai-
loring messages as well as deciding on the best method of communication in an event of
an outbreak. According to WHO’s Outbreak Communication Information Gathering Tem-
plate (2008)), questions that need to be answered are as follow:
Table 6.1: Information Gathering Template

TO IDENTIFY AT-RISK GROUPS/POPULATIONS
1. What specific groups are at risk?
2. What specific groups or partners are indirectly involved?
3. Are there groups or partners who should be considered as communication priori-
ties in light of their likelihood to be looked to for advice or direction?
4. Are there particularly vulnerable/high risk groups that need to be reached?
TO ASSESS KNOWLEDGE, AWARENESS, PERCEPTIONS
1. What do individuals and communities know about the cause and transmission of
the disease?
2. What are the local terms or descriptions of the disease?
3. What are the individual and community perceptions of risk posed by the outbreak?
4. Have these groups experienced outbreaks before and how have they managed them?
5. What are the messages circulating within the community?
TO IDENTIFY THE BEST INFORMATION SOURCES, CHANNELS, AND SETTINGS
1. Where/who do people get information from (health and other sources of advice)
and why?
2. Who are ‘trusted’ and ‘credible’ information sources and what makes them so?
E.g. health care staff/local leaders/ religious leaders/influential individuals
3. What media or channels of communication are available to promote messages?
4. What channels are most popular and influential among the different affected groups?
5. What traditional media are used?
6. What are the current patterns of social communication?
7. What active community networks and structures exist and how are they perceived
by the local population?
8. What other organizations are currently addressing the issue in the community?
(some examples of channels are: fact sheets, face-to-face communication, newslet-
ters, posters and brochures, public service announcements, news media, websites,
podcasts, text messages, and other new technologies, email messages, secure and
proprietary networks)
9. What settings are relevant to deliver communication materials and messages? (e.g.
clinic, home, village etc.)
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TO UNDERSTAND EXISTING HOUSEHOLD AND COMMUNITY PRACTICES

1. What are the - non outbreak - health-seeking and health-care practices?
2. What existing practices amplify risk and what are the beliefs and values that un-
derpin them?
3. What existing practices reduce risk, e.g. hand washing, cooking food thoroughly,
chlorination etc. and what are the beliefs and values that underpin them?
4. What are the decision-making processes within communities and the household
related to seeking health-care?
5. Are there any social and political tensions that may affect risk reduction practices?
6. Do people have access to sufficient resources to implement risk reduction practic-
es? (eg. Do people have access to clean water?)
7. Are health services available and accessible?
8. Are there problems related to transporting sick people to clinics/hospitals?
9. What existing traditional religious beliefs and social norms may inhibit imple-
menting risk reduction practices?
Source: WHO’s Outbreak Communication Information Gathering Template (2008)
6.4 Press Statement

A press statement is a short piece of news, written by the organization that wishes to dis-
seminate information relating to a specific issue. A press statement should be only three or
four paragraphs long; preferably no more than 500 words. The short news piece is sent to
members of the media; preferably the editors who are in charge of the specific field. The
handing over of the press statement task is made easier if positive relationships are estab-
lished with the media before the occurrence of an outbreak. The press release should be
issued by MOH and/or DVS. It is best if the two entities were to communicate with one
another before handing over the press release in order to avoid any miscommunication
with one another and also with the media. Here are some important steps in press state-
ment writing:
1. For time sensitive news, such as a disease outbreak, the news piece should be
labelled “FOR IMMEDIATE RELEASE” at the very top of the page.
2. Create an informative yet catchy headline that summarizes the news piece. The
headline can also contain a sub headline should there be a need to be more de-
scriptive. The headline is as important as the body of the news piece because it
may be a determining factor for editors to choose a piece for publication.
3. State the city of where the news originates from and the date of the desired news
release.
4. The first paragraph of the press statement should address the 5W 1H (who, what,
when, where, why, how).
5. The following paragraphs should provide supporting materials and details such
as direct quotes from experts, background information, palatable statistics, ac-
tion that must be taken, etc.
106
6. The press statement should end with the contact information of the person who
can respond to queries pertaining to the written issue.
7. End the press statement with three hashtag signs (# # #). This indicates the end
of the press statement.
Examples of press statements are included in the Appendix 6.1.

6.5 Debriefing - Post Outbreak Investigations
Once the outbreak investigation and response has come to a completion, a meeting (de-
briefing) involving the outbreak team members must be held. According to the Guidelines
for the Investigation and Control of Disease Outbreaks (2012), the aim of the meeting is
to examine the strengths and weaknesses of the investigation which can aid in the better-
ment of future outbreak investigations.
The meeting can be held at several time points: First, it can be held immediately after
the completion of an outbreak investigation (also known as hot debriefing). This debrief-
ing will address key health issues and immediate concerns. Second, it can be held two
to four weeks after the completion of an outbreak (also known as cold debriefing). This
debriefing will address organizational issues and the identification of the strengths and
weaknesses. The final debriefing, also known as the multi-agency debrief, can be held
during the sixth week, or depending on the need. This debriefing will take place if there
are contributions from other agencies. It should address multi agency issues as well as the
identification of strengths and weaknesses in the handling of the outbreak.
6.6 Communication Chronology

Individual elements of communication have been explained in the earlier part of this
chapter (parties involved, writing a press statement, debriefing, etc.). However, to piece
together the communication puzzle, this section addresses the elements involved accord-
ing to the communication chronology of an outbreak (before, during, and after an out-
break). Refer to Tables 6.2 – 6.4 which are adapted from WHO Outbreak Communication
Planning Guide (2008).
107
Table 6.2: Before outbreak (Preparation phase)
108
STRUCTURE TASK/ACTIVITIES METHODS
Outbreak Communication Information

Gather disease information
Gathering Template WHO
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Fact sheets, FAQ sheets, booklet, pam-

Develop basic response material
phlets, pocket book, newsletters,
Establish infrastruc- Health education materials via websites,
ture for risk commu- Hot line centre electronic and social networks, mass
nication within each Create communication channels/platforms to media, text messages,v
ministry be forwarded to all work partners
Interpersonal: group meetings, school
visits, video conferences,
Develop risk and crisis communication plan Advisory for travellers
Designate and train spokesperson(s) Provide function-specific information
Engage in advocacy to gain support needed for
effective preparation and responses
Keep open channels with local, regional and
national levels of government
Government Prepare briefing on the ‘Risk of the disease’ to
agencies the authorities in coordination with the subject
matter experts
Work partners Public health/ • Establish protocol on incident manage-

Emergency ment/emergency operations
response au- • Do simulation to make sure commu-
thorities/vector nication responders know their role and
control emergency response structure
• Organize conference/workshops/forums to address
issues on risk factors, case definitions, diagnostics
Medical personnel/ • Invite to join into technical/advisory committee/think
Health departments tank groups
• Collaborate with information hotline for clinical
Primary Defences support
• Provide information to guide hospitals to prepare
emergency response plan and patient management
Hospitals
• Establish contact person at hospital hotline for
disease management
Port authorities • Provide information for travellers health alert
• Collaborate with them to educate their members
Health Associations/ • Provide preventive messages to associations to be
NGOs/ Businesses/ distributed to the public
Secondary Defences
Industries/ Other asso- • Collaborate with them in their outreach programs to
ciations increase awareness, sensitize, and educate their local
communities/workers/employees
• Organize conference/workshops/meeting/ talks/
forums to inform them of potential issues
Academic Institutions • Invite to join into technical/advisory committee/think
(schools and higher tank groups
learning instructions) • Collaborate with the education system to develope
lessons and content in their curriculum to create
awareness of the disease and preventive measures
109
110
• Develop and mantain relationship that will support

communication activities
Media Accept media inter-
• Provide baseline information, national prepared-
views/ dialogues/
ness, response plan forum
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• Provide information public service announcements

Spokesperson interact with the press on short notice
Communicate with • Conduct baseline assessments of concern and percep- Conduct focus
public tion (CP); knowledge, attitude, practice (KAP), gender group discussions
Public issues; cultural; and religious issues and/or interviews
• Establish multiple channels to disseminate information based on questions
on risk, prevention, and prevention. listed in Table 6.1
Source: Adapted from WHO Outbreak Communication Planning Guide (2008)
Table 6.3: During outbreak (Response phase)
Establish infrastructure Hot line centre Emer- • Activate communication plan timely
for risk communication gency Operation • Designate team leader & outbreak committee
within each ministry Center (EOC) • Updating spokespersons information
Work partners Government agencies • Designate team leader & outbreak committee
• List of committee contacts compiled and disseminated
• Committee elects communication representative (focal points)
• Implement communication plan
Public health/Emer- • Establish Joint Information Center within EOC’s
gency response au- • Schedule regular meetings for outbreak teams and key
thorities/vector control elements of operational response
• Activate communication plan
• Provide updated information
Medical Personnel/ • Work in tandem when medical response plan(s) is implemented

Health Departments • Update information flow as necessary
• Easy to access/in direct contact with the information hotline
Primary Defences
for clinical support
Hospitals • Implement contigency plan with hospitals
• Obtain information from hospitals to support information
and counselling for patients and families; hospital personnel;
and associated personnel
• Use the gathered information to facilitate communications with
other sectors and the general population regarding the status of
111
the hospital operations and medical care support facility
112
Port authorities/travel and • Intensify communications services Screening at
• Provide updates concerning disease status; preventive port entries,
tourism industries
and protection actions Reporting
from travel/
tourism in-
ONE HEALTH MANUAL
dustries
Health Associations/NGOs/ • Collaborate with the leadership of these organizations
Business/Industries/Other for further prevention and protection efforts
Associations • Intensify communication: health care services, look for
disease patterns and trends; abnormality
• Provide updates concerning disease status
Academic institutions • Collaborate with the leadership of these organizations
(schools and higher learn- for further prevention and protection efforts
ing institutions) • Provide updates concerning disease status
Media • Establish a permanent channel of information for regular
interactions with media
Secondary Defences
• Issue press statement
• Prompt response to inquiries
• Use consistent spokesperson to build trust to avoid
conflicting messages from multiple sources
• Emphasize disease prevention through multiple channels
• Tackle sensitive issues with great care
• Update them concerning the status of the outbreak
• Show empathy
• Monitor press reports and coverages daily
• Conduct analysis of reports for appropriateness and
relevance and adjust messages/strategies accordingly
Public Communicate with public • Fully activate call centres with trained personnel to cater
to the public inquiries (24-hr service)
• Medical practitioners need to give accurate information
• Public awareness sessions with vulnerable groups must
be held to educate the public on preventive and control
measures
• Create a website that regularly updates information for
public access (embedded videos of press conferences,
information on the decease, immediate steps taken)
• Launch special campaigns for attitude and behavioral
changes for future prevention.
• Monitor communication channels. Assess delivery of
the messages
• Develop location specific messages and update as
appropriate
• Open local support hotlines
Source:Adapted from WHO Outbreak Communication Planning Guide (2008)
113
Table 6.4: After outbreak (Recovery phase)
114
Hotline Centre • Evaluate and adjust communication plan

Establish infrastructure
• Evaluate the timeliness of transfer of information
for risk communication Emergency Operation Cen- • Conduct debriefing
within each ministry ter (EOC)
ONE HEALTH MANUAL
Government Agencies • Evaluate effectiveness of communication activities

Identify work partners between working partners
• Conduct debriefing
Public health/ Emergen- • Continue to provide updates
cy response authorities/ • Conduct debriefing
vector control
Medical personnel/ Health • Continue to provide updaates
departments • Continue to support clinical hotline
Primary Defences • Continue debriefing
Hospitals
Port authorities/travel and • Evaluate the timeliness of response Screening at port
tourism industries • Conduct debriefing entries, Reporting
from travel/tourism
industries
Health Associations/NGOs/ • Evaluate the timeliness of transfer of information

Business/Industries/Other to their members and public
Secondary Defences • Conduct debriefing
Associations
Academic institutions • Evaluate the involvement of these organizations

(school and higher learning in the communications plan for the preparation and
institutions) response to disease
• Conduct debriefing
Media • Continue to provides updates
• Continued emphasis on messages on how to reduce risk
• Evaluate implementation of communications plan to
introduce necessary adjustment
Public Communicate with public • Evaluate the effectiveness of communication plan

• Continue updates of disease
• Continue public surveillance
• Continue public messages on prevention
Source:Adapted from WHO Outbreak Communication Planning Guide (2008)
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BIBLIOGRAPHY
LITTLEJOHN, S. W., AND FOSS, K.A. (EDS.) 2009. Encyclopedia of communication theory,
Thousand Oaks, CA: SAGE Publications.
WHO 2005. Outbreak Communication: Best Practices for Communicating with the Public
During an Outbreak. Geneva: World Health Organization.
WHO 2008. World Health Organization Outbreak Communication Planning Guide [Online].
Geneva: World Health Organization. Available: http://www.who.int/ihr/elibrary/WHOOutbreak-
CommsPlanngGuide.pdf [Accessed August 24 2016].
116
APPENDICES
ONE HEALTH MANUAL
Appendix Introduction 1: A timeline of major milestones in the development

and implementation of the One Health concept
TIME EVENT
Approximately Hippocrates urged physicians that all aspects of their patients’ lives
400 BCE need to be considered including their environment
Rudolph Virchow first used the term ‘zoonosis’ for infections acquired
1855
from animals
An international group, Wildlife Trust, formed by naturalist Gerald
1971
Durrell. The Wildlife Trust is now known as EcoHealth Alliance
Calvin Schwabe, veterinary epidemiologist coined the term ‘One Med-
1984
icine’
Institute Of Medicine release the report, ‘Emerging infections: Micro-
1992
bial Threats to Health in the United States’.
Federation of American Scientists and WHO sponsored a meeting in
1993
Geneva to discuss the potential threat of biological warfare
Launch of the Program for Monitoring Emerging Diseases (ProMED)
1994
(Morse et al. 1996)
The Global outbreak alert and Response Network (GOARN) con-
2000
ceived and development begun
‘Microbial Threats to Health: Emergence, Detection and Response’ Re-
2003
port released by IOM
Human Animal Infections and Risk Surveillance (HAIRS) begins oper-
2004
ation in the UK
2004 Manhattan Principles are defined in a meeting on ‘One World One
September Health’ convened by the Wildlife Conservation Society
International Health Regulations agreed by the World Health Assem-
2005
bly (WHO), and implemented in 2007
2005
United Nations Systems for Influenza Coordination formed (UNSIC)
September
The Asia Pacific Strategy for Emerging Diseases (APSED) implement-
2005
ed
First International Ministerial Conference on Avian Influenza and Pan-
2006 January
demic Influenza (IMCAPI) Beijing, PR China
The Global Early Warning System for major Animal Diseases
2006
(GLEWS) developed and implemented by FAO, OIE and WHO
2006
Second IMCAPI Bamako, Mali
December
American Veterinary Medicine Association (AVMA) was instrumental
2007 in forming the One Health Initiative Taskforce (OHITF) (King et al.
2008)
118
APPENDICES
TIME EVENT
2007
Third IMCAPI New Delhi, India
December
The South Africa Centre for Infectious Disease Surveillance (SACIDS)
2008 January established as a One Health Virtual Centre linking research institutions
in Tanzania, DRC, Mozambique, Zambia and South Africa
The One Health Initiative (OHI) www.onehealthinitiative.com, a major
2008
internet based communications resource launched
2008 October Fourth IMCAPI Sharm el-Sheikh, Egypt
FAO, OIE, WHO, UNICEF, World Bank and UNSIC produce collab-
orative document ‘Contributing to One World, One Health. A Strate-
2008 October gic Framework for Reducing Risks of Infectious Disease at the An-
imal-Human-Ecosystem Interface’ endorsed by IMCAPI at Sharm
el-Sheikh
Expert international consultation held in Winnipeg ‘One World One
2009 March
Health: from Ideas to Action’
A national (USA) One Health Commission (http://www.onehealth-
commission.org) formed following recommendations of the OHITF,
with AVMA, the American Medical Association, the American Public
2009 Health Association, the Association of American Medical Colleges, the
Association of American Veterinary Medical Colleges, the American
Society for Microbiology, and the Infectious Disease Society of Ameri-
ca as partners, and funded by Rockefeller foundation
Afrique One, an African Research Consortium on Ecosystem and Pop-
2009 ulation Health, launched with members from West and East Africa with
three European partners
One Health Alliance of South Asia (OHASA) formed as a network of
2009
scientists in Bangladesh, India, Nepal, and Pakistan
2010 April Fifth IMCAPI Hanoi
Tripartite concept Strategy – An FAO-OIE-WHO collaboration to ad-
2010 April dress health risks at the animal –human-ecosystems interface’ is en-
dorsed
Centers for Disease Control (CDC) Stone Mountain meeting initiates
2010 May
seven international working groups to progress aspects of One Health
World Bank publishes ‘People, Pathogens and our Planet: Vol 1. To-
2010
ward a One Health approach for Controlling Zoonotic Disease’.
‘Connecting Organizations for Regional Disease Surveillance
2010 (CORDS)’, a non-government platform connects global regional sur-
veillance systems
2011 February First International One Health Congress Melbourne, Australia
119
ONE HEALTH MANUAL
TIME EVENT
One Health Central and Eastern Africa (OHCEA) formed as a network
2011 of 14 public health and veterinary institutions in Ethiopia, Uganda,
Kenya, Tanzania, DRCongo and Rwanda
One Health Global Network, an information clearing house, is
2012
launched
World Bank publishes ‘People, Pathogens and Our Planet: Vol 2. The
2012
Economics of One Health’
Global Risk Forum One Health Summit ‘One Health, One Planet, One
2012 February
Future’ held in Davos, Switzerland
2013 January Second International One Health congress Bangkok, Thailand
The Gates Foundation calls for One Health research through the Grand
2013
Challenge program
One Health Summer Schools available in Denmark, England and Aus-
2014 tralia. Masters in One Health offered in USA and UK, and a doctorate
in the USA
Sources: Mackenzie JS, Mckinnon M and Jeggo M, 2014. P166-167
120
APPENDICES
Appendix Introduction 2: Epidemiologic Steps in Outbreak Investigation

(from 3 sources)
10 STEPS 13 STEPS 7 STEPS (HEALTHKNOWL-
(GREGG) (CDC) EDGE.ORG.UK)
1. Determine the exis- 1. Prepare for field work 1. Preliminary assessment
tence of the epidemic in outbreak investigation
2. Establish the existence (to confirm existence of
2. Confirm the diagnosis of an outbreak outbreak)
3. Define a case and 3. Verify the diagnosis
2. Case definition and
count cases identification
4. Construct a working case
4. Orient the data in definition 3. Descriptive study
terms of time, place,
and person 5. Find cases systematically 4. Analytical study of an
and record information outbreak
5. Determine who is at
risk of becoming ill 6. Perform descriptive epi- 5. Verify hypothesis
demiology
6. Develop a hypothe- 6. Institute control mea-
sis that explains the 7. Develop hypotheses sures
specific exposure that 8. Evaluate hypotheses epi-
caused disease and 7. Communicate
demiologically
test this hypothesis by
appropriate statistical 9. As necessary, reconsider,
methods refine, and re-evaluate
hypotheses
7. Compare the hypoth-
esis with established 10. Compare and reconcile
facts with laboratory and/or
environmental studies
8. Plan a more systemat-
ic study 11. Implement control and
prevention measures
9. Prepare a written re-
port 12. Initiate or maintain sur-
veillance
10. Execute control and
prevention measures 13. Communicate findings
Sources: Gregg MB (2008). Conducting a field investigation, p97, In Gregg MB (ed) Field
Epidemiology, 3rd ed. Oxford University Press.
CDC (2012). Principles of Epidemiology in Public Health Practice, 3rd ed. P6-8. Available at
http://www.cdc.gov/ophss/csels/dsepd/ss1978/ss1978.pdf
Healthknowledge.org.uk. The steps in outbreak investigation including the use of relevant

epidemiological methods. http://www.healthknowledge.org.uk/public-health-textbook/dis-
ease-causation-diagnostic/2g-communicable-disease/outbreak-investigation
121
ONE HEALTH MANUAL
Appendix Introduction 3: District planning for outbreak management

OUTBREAK OUTBREAK MANAGEMENT COMPONENT INDIVIDUAL
MANAGEMENT OR GROUP
STEP RESPONSIBLE
Preparation • Development of outbreak protocols e.g., State and Dis-
• Designation of outbreak coordinator trict outbreak coor-
• Identification of outbreak management team dinators
that can cover all important outbreak scenarios
• Assembling materials necessary for outbreak
investigation and response
• Identification of and addressing training needs
Routine • Operation of a comprehensive infectious dis- e.g., Officer in
ease surveillance system at the district level charge of Crisis
surveillance • Collection of notifications from clinicians and Preparedness and
laboratories Response Centre
• Collection of data on self-reported cases and (CPRC), Epidemi-
other ‘informal’ reporting sources ology Officer, etc.
• Integration of local surveillance data from
multiple sources
• Collection of descriptive information on indi-
vidual cases of disease with outbreak potential
• Development of links with hospital infection
control personnel
Identification • Regular examination of surveillance data to e.g., Officer in
detect increases in disease incidence and com- charge of Crisis
mon risk factors Preparedness and
• Maintenance of good systems to receive and Response Centre
evaluate reports of outbreaks from local health (CPRC), Epidemi-
professionals and others agencies ology Officer, etc.
Description • Collection of information on cases involved e.g., Outbreak man-
with outbreaks agement team
• Development of outbreak case definition
• Characterisation of outbreak by person, place
and time
• Development of hypotheses
• Identification of need for further investigation
Investigation • Capacity for epidemiological investigation e.g., Outbreak man-
• Capacity for environmental investigation agement team
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APPENDICES
OUTBREAK OUTBREAK MANAGEMENT COMPONENT INDIVIDUAL

MANAGEMENT OR GROUP
STEP RESPONSIBLE
Control • Implementation of control measures, includ- e.g., District Health
ing those requiring medical officer of health Officer, Food Tech-
responsibility nologist (Food
Quality and Safety
Programme), Envi-
ronmental Health
Officer
Communication • Immediate reporting of outbreaks of national e.g., Outbreak coor-
importance to the Ministry of Health dinators
• Communication with media about district
outbreaks
Documentation • Documentation of outbreak e.g., Outbreak coor-
and reporting • Timely and accurate reporting of all outbreaks dinators
via outbreak surveillance system. Initial re-
ports within one week of recognition, updat-
ed weekly, final record within one week of
completion
Sources: Institute of Enivronmental Science & Research Limited (updated 2012). P15-16
123
ONE HEALTH MANUAL
Appendix Introduction 4 – Case Studies

Case study 1: West Nile virus, New York City, 1999
An unusual arboviral encephalitis outbreak was recognized in NYC in August, 1999. On
23 August, an infectious disease physician from a Queens hospital contacted the NYC
Department of Hygiene and Mental Health (NYCDOHMH) to report two encephalitis pa-
tients. NYCDOHMH then conducted a city-wide investigation that revealed a cluster of
six encephalitis patients, five having profound muscle weakness, and four requiring re-
spiratory support. Initial clinical sample tests from these patients by the CDC revealed
that they were positive for Saint Louis encephalitis, on 3 September. Additional encepha-
litis cases ensued. As eight of the earliest cases were residents of a 2-square-mile area in
Queens, aerial and ground applications of mosquito pesticides began in northern Queens
and South Bronx on 3 September.
Active encephalitis surveillance began in NYC on 30 August, and in nearby Nassau and
Westchester counties on 3 September. A clinical case definition was used. Before and
during this outbreak, an observed increase in bird deaths (particularly crows) was noted in
NYC. Tissue specimens from birds in the Bronx Zoo were analysed by the CDC, which
revealed on 23 September that the virus was WNV-like in genetic composition. Up to that
time, WNV had never been isolated in the Western hemisphere
Concurrently, brain tissue from three NYC encephalitis case deaths tested positive for
WNV at the University of California at Irvine. As of 28 September 1999, 17 confirmed
and 20 probable cases had occurred in NYC, Nassau, and Westchester counties, with
four deaths. Onset dates were from 5 August to 16 September, and the median age of the
case-patients was 71 years (range 15–87 years). By 5 October, the number of laborato-
ry-positive cases increased to 50 (27 confirmed and 23 probable). The NYCDOHMH es-
tablished emergency telephone hotlines on 3 September, with 130,000 calls received by
28 September. They distributed over 300,000 cans of DEET-based mosquito repellent
city-wide through local firehouses, and 750,000 public health leaflets with information
on protection from mosquito bites. They provided public health messages by radio, televi-
sion, and via the Internet. A seroprevalence survey later determined that about 100 asymp-
tomatic infections and 30 WNV fever cases occurred for each WNV encephalitis case in
the NYC area.
Within its normal geographic area of distribution in Africa, West Asia, and the Middle
East, birds do not normally show symptoms when infected with WNV. Migrant birds
from this part of the world are thought to cause occasional WNV epidemics in Europe. An
epizootic that results in the deaths of large numbers of birds may represent introduction
into a new population or a new more virulent strain of a virus.
WNV is primarily transmitted by Culex pipiens mosquitoes, which also contributed to its
subsequent spread in the United States. This prompted nationwide mosquito population
surveillance. Genetic testing revealed that the virus was 99% identical to one isolated in
1999 from a goose in Israel. Potential routes for introduction of this virus include impor-
tation of WNV-infected birds, mosquitoes, or sick persons. The WNV-prevalent area of
NYC included two large international airports. In WNV encephalitis patients, computer
124
APPENDICES
assisted tomography often revealed pre-existing lesions and chronic changes in brain tis-
sue, suggestive of a greater susceptibility to deleterious outcome in the elderly.
Learning Point:
This outbreak emphasized the important relationship between veterinarians, physicians, and
Public Health in disease surveillance, and that uncommon pathogens must be considered.
Among the epidemiological ‘lessons learned’ from the 1999 WNV outbreak was the example
of a typical disease pattern seen with a natural epidemic, occurring first among birds, fol-
lowed by cases of human illness. With the establishment of WNV in indigenous North Amer-
ican mosquito vectors, the virus has spread and become endemic to the continent. Important-
ly, the origin of outbreaks fitting some clues for a biological attack (e.g. a new disease in a
geographic region), cannot be determined without extensive investigation. Emerging diseases,
both new to a region like WNV, and a totally new pathogen (e.g. SARS), have occurred in the
last decade. Regardless of outbreak origin, the epidemiological methods remain the same.
(Source: Asnis DS. et al. The West Nile Virus outbreak of 1999 in New York: The Flushing hos-
pital experience. Clinical Infectious Diseases. 2000;30:413–418.)
125
ONE HEALTH MANUAL
Appendix Introduction 5: One Health Core Competencies by Proficiency Levels

(Note: The One Health core competencies are seen as an addition to a practitioner’s
expertise in their professional field)
National One Health Policy Leader

• Collaboration: Develops and helps sustain network of diverse stakeholders to build/
leverage strategic relationships that have the ability to achieve common goals.
• Diplomacy: Uses diplomacy and conflict resolution strategies with partners. Builds trust
within partnerships.
• External Awareness: Socio-cultural and political savvy. Understands and keeps up-to-
date on global policies and trends that affect the One Health movement; is aware of the
impact One Health has on related professions.
• Vision Integration: Takes long-term view to ensure sustainability relevance of One
Health movement. Uses cost-effectiveness thinking to set priorities. Analyses distribu-
tion of resources to meet current One Health goals. Develops monitoring and evaluation
frameworks to assess programs and policies. Makes decisive decisions that are informed
by evidence and take the political and historical context into account.
• Communicates lessons learned to global networks; advocates for new One Health pro-
grams by sharing success stories.
• Management experience: Is able to bring diverse stakeholders to the table to accom-
plish agreed-upon One Health goals.
One Health Program/ Project Manager

• Builds Diverse Team: Assembles team with a variety of backgrounds and that rep-
resent human, animal, and environmental health expertise. Engages state and/or local
populations in making decisions that affect their health and well-being. Facilities coop-
eration among members.
• Human Capital Management: Gives actionable feedback and support. Manages and
resolves conflicts. Promotes personal accountability in professional practice. Encourages
ongoing training, critical thinking, and new ideas and their integration among health disci-
plines. Support others in their One Health professional development.
• Strategic Thinking: Formulates objectives and priorities; implements plan. Under-
stands, interprets, and evaluates surveillance data. Identifies methods for assuring pro-
gram sustainability within context of larger One Health movement. Is able to articulate
and explain the sustained multiple avenues and contributions of One Health concepts to
the overall development of biomedical science, preventive medicine, and disease control
programs in both humans and animals.
• Resource Management: Financial: Prepares, justifies and administers program budget.
Develops proposals to secure funding and foster stakeholder support. Technology: Makes
effective use of technology to achieve goals; ensures access to and security of technology
resources.
• Communicates lessons learned to workforce and community partners.
• Field/outbreak experience: Works successfully on a multidisciplinary team to achieve
common goals and recognize unique of stakeholders.
126
APPENDICES
Field/Entry Level
• Integrity: Behaves in an honest, fair, and ethical manner. Strong work ethic.
• Interpersonal Skills: Able to collaborate with One Health partners from diverse back-
grounds in order to reach common goals. Treats others with courtesy, sensitivity, and re-
spect, respond appropriately in different situations. Seeks to understand unique interest of
One Health partners and maximize them to the extent possible.
• Communication: Communicates in clear, concise, organized, and convincing manner
both in writing and orally, in person, and through electronic means. Listens effectively;
clarifies information as needed.
• Problem Solving: Identifies and analyses problems; weighs relevance and accuracy of
information while considering the perspectives of all stakeholders; generates and evalu-
ates solutions; makes recommendations.
• Flexibility: Rapidly adapts to new information, changing conditions, or unexpected ob-
stacles. Recover quickly from setbacks.
• Self-Development: Assesses and recognizes own strengths and weaknesses; pursues
professional and personal development.
• Knowledge of the history of One Health.
Source: William Hueston, Rebekah Kunkel, Felicia Nutter, and Debra Olson (2014). One
Health Core Competencies. Copied from http://www.aavmc.org/data/files/annualconfer-
ence/2014/ppt/kunkel.pdf on 6 April 2016
127
ONE HEALTH MANUAL
Appendix 3.1 Outbreak Investigation Laboratory Guideline Checklist

General tools
» Sterile spoons, spatulas and gloves
» Method for surface sterilisation (e.g., chemical disinfectant)
» Laboratory test request forms
» ‘Bio-bottles’, chiller-bins, chiller-pads, labels
Tools for food, water and environmental specimens
» Containers for food, water and environmental specimens
» Sterile plastic bags or unopened containers for food, fluids and environmental
material (e.g., potting mix)
» Sterile bottles (250 mL) for water to test for indicator organisms and Legionella
» Sterile dry swabs (i.e., without media) for environmental swabs
Tools for clinical specimens
» Sterile bottles for faeces, vomit specimens
» Additional items for collecting clinical specimens
» Phlebotomy supplies for blood/serum, including tubes with and without antico-
agulant (EDTA)
» Specimen container for urine – may need preservative
» Specimen container for chemical toxins, may need to be pre-screened to elimi-
nate background contamination
» Throat and nasopharyngeal swabs, plain and with viral transport media
Document
» Specimen label » Writing pens and pencils
» Case investigation forms » Outbreak investigation
» Patient register book » Outbreak investigation guidelines
» Marker pen
Personal Protective Equipment
» Gowns/coveralls » Disinfectants – JIK, soap, 70%
» Plastic apron alcohol, 10% Povidone iodine
» Masks » Goggles
» Cups » Scrub suits
» Biohazard bags » Gloves – (surgical and disposable)
Specimen Collection, Packaging, Transportation and Referral
» Racks » Vacutainer sleeves
» Needles » Adhesive tape
» Tourniquet » Lancets
» Cotton wool » Stool containers
» Alcohol swabs » Water sampling kits
» CSF collection kit » Gauze large pack
» Leak proof screw capped container » Filter Paper
» Vacutainers » Slides
128
APPENDICES
» Cover slips » Immersion oil

» Skin snip kits » Lens tissue
» Formalin + Coplin jar » Water testing kits
» Cryotubes » Transport media
» Plastic Pasteur pipettes » Triple packing systems
» Absorbent materials » Colds box
» Parafilm (small rolls) » Cold packs
» Thermometers » Sterile cotton tipped applicator (e.g.
» Tongue depressors for rectal swab)
» Kit boxes » Blood culture bottles
» Slide boxes » Sputum containers
» Staining racks » Safe box/bio safety bags
» Microscopes (light binoculars) » Normal saline
129
ONE HEALTH MANUAL
Appendix 3.2 Checklist of General Tools & Equipment for Different Range of Specimen
Preparation on personal protective equipment (PPE):
□ Detergent hand wash □ Disposable glove
□ Disposable absorbent (paper) towel □ Protective gown or coverall
□ Surgical Mask or N95 mask □ Wear shoes with puncture-resistan
□ Goggle or eye visor (if required) sole or rubber boots
SAMPLE TYPE MEDICAL VETERINARY

CLINICAL SPECIMENS
Blood sampling • Sterile blood collection • Large animal (ruminant, equine,
tube hoofed-stock wild animal, big
□ without anticoag- mammal)
ulant □ 10 ml Plain tube – uncoag-
□ with anticoagulant ulated tube
– EDTA or heparin □ 10 ml EDTA or heparin
• Blood sampling system coagulated tube
□ Needle and syringe □ Venoject needle (sizes
system, vacuum range from G 16 to G 23)
extraction system □ Venoject needle holder
with holder and □ 70 % Alcohol swab or
winged butterfly cotton ball
catheter
• Tourniquet □ Cotton
• Skin antiseptic solution 70 □ Rack for holding blood
% alcohol tubes
• Gauze pads □ Durable marker for label-
• Adhesive bandage ling on each samples
• Tray for assembling blood
collection tools • Small animal, avian species, rep-
tiles, small mammal and fish
• Rack for holding blood
tubes □ Hypodermic needle or but-
• Durable marker for label- terfly catheter sizes range
ling on each samples from G 23 to G 26)
□ Syringe (range volume
from 0.5, 1, 3, 5 ml)
□ 70 % Alcohol swab or
cotton ball
□ Cotton
□ Durable marker for label-
ling on each samples
130
APPENDICES

Fresh faeces/stool □ Sterile swab □ Sterile swab
and rectal swab □ Transport media □ Transport media eg: amies
eg: Cary-Blair medium
transport medium □ Sterile container to keep
□ Sterile container to fresh faeces
keep fresh faeces □ Antiseptic solution 70 %
□ Antiseptic solution alcohol to disinfect the
70 % alcohol to container
disinfect the con-
tainer
□ Preservative solu-
tion-10% formalin
or 10% polyvinyl
alcohol (parasites
investigation)
Vomitus, sputum □ Sterile specimen □ Sterile specimen container
container with with screw-cap
screw-cap □ Sterile spatula
Urine (midstream □ Sterile specimen □ Sterile specimen container
urine) container with with screw-cap
screw-cap
Oropharynx/nos- □ Sterile swab □ Sterile swab
tril swab, vaginal/ □ Transport media o 10-15 cm length for
uterine swab, avian, small animal and
swab on wound new born
and skin o 35-40 cm length for
large animal (use short
swab if swabbing on
superficial)
□ Transport media
Pus-containing □ Syringe
Granuloma, pus- □ Needle
tule, vesicle
□ Alcohol
□ Cotton
131
ONE HEALTH MANUAL

Fine needle aspi- □ Shaver
ration, biopsy, □ Disinfectant
□ Tincture iodine
□ Gauze and cotton
□ Fine Needle eg: 24 or 25 G
1-1 1/2’
□ 10 ml syringe
□ Ultrasound
□ Glass slide
□ Sterile screw-cap container
□ Marker pen
Ascites, thora- □ Shaver
cocentesis and □ Disinfectant
abdominocentesis
□ Tincture iodine
□ Gauze and cotton
□ Syringe
□ Needle 21 or 23 G
□ Catheter
132
APPENDICES

FOOD SPECIMENS
Food specimen • Sterile sample containers • Sterile sample containers

□ Disposable plastic • Triers (taking sample from sacs)
bags • Spoons or scoops
□ Wide-mouth jars • Clean and dry zip lock plastic for
(100-1000 ml) grain and roughage
with screwcap • Marking pen
□ Foil or heavy • Adhesive tape
wrapping paper • Sterile swab
□ Metal cans with • Transport media
tightly fitting lids
• Spoons, scoops or tongue
depressors
• Forceps, tongs, spatula
• Drill bits
• Scissors
• Sterile knife
• Food temperature mea-
surement with Bayo-
net-type thermometers
(-20 oC to 110 oC)
• Heavy-duty plastic bag
• Marking pen
• Adhesive tape
• Cotton
• Peptone or buffered saline
• Electric drill (sampling
frozen food)
• Distilled water
• Sterile swab
• Enrichment broth
• Polystyrene box
Liquid food, wa- □ Sterile container □ Sterile container with
ter or beverages with screw-cap screw-cap
□ Sterile swab □ Sterile swab
□ Transport media □ Transport media
133
ONE HEALTH MANUAL

ENVIRONMENTAL SPECIMENS
Environmental □ Sterile swabs □ Sterile swabs

swab □ Sterile absorbent □ Sterile absorbent material
material eg: rayon, eg: rayon, polyester (use in
polyester (use in big surface area)
big surface area) □ 0.1% peptone water
□ 0.1% peptone □ Sterile PBS or sterile dis-
water tilled water
□ Enrichment media □ Enrichment media
Soil sample □ Soil –sampling probe; an

auger, a spade or shovel
(stainless steel)
□ Clean and dry zip lock
plastic
Water sample • Sterile container with • Sterile container with screw-cap
screw-cap • Enrichment media
• Moore swab (sample from
stream or plumbing)
• Enrichment media
Organ samples • Not Applicable • Post Mortem Kit
from animal □ Dissecting scissors
(Field Sampling)
□ Mayo scissors
□ Curved Knife
□ Tissue forceps blunt end
□ Tissue forceps with tooth
□ Knife sharpener
□ Bone cutter
□ Bone sew
□ Scalpel Handle #3
□ Scalpel Handle #4
□ Scalpel Blade
□ Mallet Round
□ Chisel
□ Tissue Containers
□ Formalin in tightened jar
□ Other Instruments Required
134
Appendix 3.3 Laboratory testing for different diseases
NO DISEASES AUTHORITY SAMPLE ISOLATION AND MOLECULAR SEROLOGY TEST LABORATO-
TYPES IDENTIFICATION TECHNIQUES TECHNIQUES RY
1. Brucellosis Veterinary Serum ELISA (exclude Veterinary Region-
B. suis) al Laboratories
(B. abortus,
VRI
B. melitensis,
B. suis)
Serum CFT VRI

Whole RBPT (exclude Veterinary Region-
blood B. suis) al Laboratories
VRI
Milk PCR (exclude B. MRT (for B. VRI

suis) abortus only)
Organs and Primary culture PCR VRI
aborted media: Blood agar,
foetus, en- Mac Conkey agar,
vironmental biphasic agar
swabs
Enrichment media:
serum dextrose agar
and Brucella selec-
tive media
135
APPENDICES
NO DISEASES AUTHORITY SAMPLE ISOLATION AND MOLECULAR SEROLOGY TEST
136
TYPES IDENTIFICATION TECHNIQUES TECHNIQUES LABORATORY
Medical Blood Culture and sensitivity PCR and HRM ELISA Local hospital
for species iden- laboratories
Serum tification
IMR
Isolate
ONE HEALTH MANUAL
IMR
2. Leptospirosis Veterinary Serum MAT VRI

Urine, PCR VRI
kidney,
Bacteria
culture
Brain, kid- Primary culture: VRI
ney, liver Semisolid EMJH
or pooled Veterinary Regional
organs Laboratoriesoraa-
tory
Medical Serum IgM screening Local Hospital
(ELISA/LA- Laboratories
Serum TEX/ICT)
IMR/Regional
Blood MAT MKA
(EDTA),
Urine, Post PCR and MLST IMR
Mortem
Tissues
3 Salmonellosis Veterinary Oragans, In- Selective Media: PCR VRI
(S.enteriti- testine, Faeces,
Cloacal Swab, XLD, BGN and Mac Veterinary Region-
dis, S/thy- Conkey Agar al Laboratories
phimurium, Environmental
S.parathy- Swab, Egg,
phimurium, Water, Feed
S.pullorum)
Salmonella Salmonella Serotyping VRI

Culture Plate
Medical Blood/Stool/ Culture and sensi- Local Hospital

(S.enteriti- Rectal Swabs tivity Laboratories
dis, S.thyph- Isolates Serotyping IMR,
imurium)
MKAK
4. Tuberculosis Veterinary Plasma ELISA VRI

(M.Bovis)
137
APPENDICES
138
Respiratory Selective media: VRI
discharges, Lowenstein Jensen,
faeces, milk, Stonebrick or Mid-
urine, semen, dlebrook media
ONE HEALTH MANUAL
abscess (lung
and lymph
node), envi-
ronmental
swabs
Primary culture: VRI
Semisolid EMJH
Veterinary Regional
Laboratoriesoraa-
tory
Medical Isolate Identification Multiplex PCR Laboratories
(M.tubercu-
losis) Uncoagulated MKAK
blood (EDTA)/
Isolate
5. Q Fever Veterinary Serum ELISA VRI
Milk, respira- PCR VRI
tory and repro-
ductive organs,
environmental
swabs
Medical Blood PCR ELISA IMR
6. Anthrax Veterinary Blood from Selective media: 3 % VRI
orifices and or- sheep RBC agar
gans, environ-
mental swabs
Blood from PCR VRI
orifices and or-
gans, Bacterial
culture
Blood from PCR VRI
orifices and or-
gans, Bacterial
culture
Formites Primary culture: BHI VRI
(powder, enve-
lope etc)
Selective media: 3 %
sheep RBC agar
Medical Any relevant VRI

samples
7. Nipah Veterinary Serum Tissue culture VERO ELISA VRI
cell
VNT
Medical Serum, CSF Nipah IgM/IgG IMR
139
APPENDICES
NO DISEASES AUTHORITY SAMPLE TYPES ISOLATION AND MOLECULAR SEROLOGY TEST
140
IDENTIFICA- TECHNIQUES TECHNIQUES LABORATORY
TION
8. Rabies Veterinary Brain, Whole Blood VRI
Brain FAT, Tissue VRI
Culture
ONE HEALTH MANUAL
Medical 10 hari follicles PCR IF IMR

from nape of neck,
saliva, CSF
Medical Isolate Identification Multiplex PCR Laboratories
(M.tubercu-
losis) Uncoagulated blood MKAK
(EDTA)/Isolate
9. Japanese B Veterinary Serum ELISA VRI
Encephalitis
Brain, CSF, spinal PCR VRI
cord, blood (EDTA)
Brain, CSF, Spinal Tissue Culture VRI
Cord
10. HPAI Veterinary Serum HI VRI
Veterinary Re-
gional Laborato-
ries
NO DISEASES AUTHORITY SAMPLE TYPES ISOLATION AND MOLECULAR SEROLOGY TEST
IDENTIFICA- TECHNIQUES TECHNIQUES LABORATORY
TION
Pooled organs Egg inoculation RT-PCR VRI
(brain, trachea,
lung, spleen), VRI
intestine, tracheal Veterinary Re-
swab, cloacal swab, gional Laborato-
environment swab, ries
oropharyngeal
swab, allantoic fluid
Medical Respiratory Sample PCR
11. Hanta Virus Veterinary Feces, Urine, Sal- Tissues Culture VRI
ivary swab, Envi-
ronmental swabs,
Organs
Medical Organs PCR Hanta IgM/IgG IMR
12. Rift Valley Veterinary Organs Tissues Culture VRI
Fever
Medical Serum PCR IMR
13. BSE Veterinary Obex Western Blot VRI
vCJD Medical Brain, CSF Western Blot IMR
14. Filariasis Veterinary Buffy Coat Wet Mount VRI
(Brugia malayi Giesmsa Staining
subperiodic)
Medical Blood Knott’s technique VRI
141
APPENDICES
or direct smear
ONE HEALTH MANUAL
APPENDIX 4.1 Example of a Questionnaire
SOAL SELIDIK LEPTOSPIROSIS
ID.No..................
Kes / Kawalan.....
1. MAKLUMAT AM
a) Nama ...........................................................................
b) No Telefon. .................................................................
c) Umur ................. tahun
d) Jantina ( ) lelaki ( ) perempuan
e) Bangsa ..........................................................................
f) Pekerjaan .......................................................................
g) Alamat ...................................................................................................
h) Koordinat GIS.........................................................................................
i) Tinggal di alamat sejak................... tahun
j) Penyakit ko-morbid yang lain: ( ) tiada ( ) ya
Jika ya, sila nyatakan...............................
2. TEMPAT TINGGAL DAN PERSEKITARAN RUMAH

2.1 Topografi dan persekitaran di sekeliling kampung dalam 500 meter
a) ( ) Dataran
b) ( ) Dusun/kebun
c) ( ) Pasar
d) ( ) Sawah padi
e) ( ) Kaki gunung / hutan
f) ( ) Bakau
g) ( ) Kolam / tasik
2.2 Alam Sekitar

a) Tempat tinggal kelihatan lembap ( ) tiada ( ) ya
b) Banjir berlaku sebulan sebelum diagnosis ( ) tiada ( ) ya
c) Mempunyai tikus banyak ( ) tiada ( ) ya
d) Mempunyai haiwan ternakan di kawasan rumah ( ) tiada ( ) ya, jenis ternakan?..............
e) Mempunyai haiwan ternakan di kawasan jiran ( ) tiada ( ) ya, jenis ternakan?.................
2.3 Di mana tempat kerja? ..................................................................................

a) Tempat kerja kelihatan lembap ( ) tiada ( ) ya
b) Tempat kerja mempunyai haiwan ternakan ( ) tiada ( ) ya, jenis ternakan?..............
c) Tempat kerja mempunyai haiwan ternakan ( ) tiada ( ) ya, jenis ternakan?..............
142
APPENDICES
3. SEJARAH SAKIT
a) Tarikh Onset.........................................................................................
b) Tempat pertama dapat rawatan selepas onset......................................................
c) Tarikh pulih.....................................................................
3.1 Gejala (dari onset sampai pulih)

a) Demam akut ( ) tiada ( ) ya
b) Kesejukan ( ) tiada ( ) ya
c) otot lenguh ( ) tiada ( ) ya
d) sakit betis apabila ditekan ( ) tiada ( ) ya
e) sakit kepala Teruk ( ) tiada ( ) ya
f) Leher kejang ( ) tiada ( ) ya
g) Mata merah ( ) tiada ( ) ya
h) Jaundis ( ) tiada ( ) ya
i) batuk kering ( ) tiada ( ) ya
j) batuk berdarah ( ) tiada ( ) ya
k) Muntah darah merah ( ) tiada ( ) ya
l) Najis hitam pekat ( ) tiada ( ) ya
m) Air kencing pekat ( ) tiada ( ) ya
n) Kencing sakit ( ) tiada ( ) ya
4. FAKTOR RISIKO
4.1 KELAKUAN RISIKO DALAM 30 HARI SEBELUM SAKIT
4.1.1 Hubungan dengan sumber air semulajadi (sungai/kolam/air terjun)

a) Bermain dalam air / berenang ( ) tiada ( ) ya, jika ya Tempat? ........jam / hari? .......
b) Berjalan dalam lumpur ( ) tiada ( ) ya, jika ya Tempat? ................. jam / hari? .......
c) Tercekik air ( ) tiada ( ) ya, jika ya Tempat? ................. jam / hari? .......
d) Minum air ( ) tiada ( ) ya, jika ya Tempat? ................. jam / hari? .......
4.1.2 Menangkap Ikan di sungai/kolam( ) tiada ( ) ya,

jika ya Tempat? ........jam / hari? .......
a) Menyelam semasa menangkap ikan ( ) tiada ( ) ya
b) Tercekik air semasa menangkap ikan ( ) tiada ( ) ya
c) Memotong & membuka ikan ( ) tiada ( ) ya
4.1.3 Luka
4.1.3.1 Mempunyai luka sebelum menangkap ikan ( ) tiada ( ) ya
a) luka jenis gores ( ) tiada ( ) ya, jika ya luka menyentuh air ( ) tiada ( ) ya
b) luka jenis terkoyak ( ) tiada ( ) ya, jika ya luka menyentuh air ( ) tiada ( ) ya
4.1.3.2 Mempunyai luka semasa tangkapan ikan ( ) tiada ( ) ya

a) luka jenis gores ( ) tiada ( ) ya, jika ya luka menyentuh air ( ) tiada ( ) ya
b) luka jenis terkoyak ( ) tiada ( ) ya, jika ya luka menyentuh air ( ) tiada ( ) ya
143
ONE HEALTH MANUAL
4.1.4 Terdedah dengan Haiwan () tiada () ya

a) ( ) tetikus: ( ) tangkapan ( ) potong terbuka ( ) makan ( ) lain .........
b) ( ) anjing: ( ) tangkapan ( ) potong terbuka ( ) makan ( ) lain .........
c) ( ) ternakan spt lembu/kambing: ( ) tangkapan ( ) potong terbuka
( ) makan ( ) lain .........
d) ( ) babi: ( ) tangkapan ( ) potong terbuka ( ) makan ( ) lain ........
e) Sentiasa membasuh tangan sebaik selepas Terdedah dengan Haiwan
( ) tiada ( ) ya
4.1.5 Makanan
a) Makan makanan yang semalaman dan terlupa untuk memanaskan lagi
( ) Tiada ( ) ya
b) Makan makanan yang kekal yang terlupa untuk menyimpan dalam kabinet
makanan ( ) Tiada ( ) ya
c) Mencuci tangan sebelum makan ( ) Tiada ( ) ya
4.1.6 Jenis air minum

a) ( ) Hujan ( ) Sungai/GFS ( ) kolam ( ) Botol ( ) Perigi
b) ( ) Mendidih ( ) tidak mendidih
4.2 PPE SEMASA TERDEDAH SUMBER AIR / LUMPUR / KEADAAN LEM-

BAP
a) memakai kasut ( ) tiada ( ) ya
b) memakai sandal/selipar ( ) tiada ( ) ya
c) memakai kasut kanvas ( ) tiada ( ) ya
d) memakai but ( ) tiada ( ) ya
e) memakai seluar panjang ( ) tiada ( ) ya
f) memakai baju lengan panjang ( ) tiada ( ) ya
g) memakai sarung tangan ( ) no ( ) ya
h) basuh kaki selepas selesai dengan segera ( ) tiada ( ) ya
i) sentiasa mandi balik dirumah selepas bermain air / berenang ( ) tiada ( ) ya
Nama penyiasat....................................................................
Tarikh...................................................................................
Msj/lepto
144
APPENDICES
APPENDIX 6.1: Examples of Press Statements
Example 1:
FOR IMMEDIATE RELEASE
PRESS STATEMENT
DIRECTOR-GENERAL OF HEALTH MALAYSIA
FIRST ZIKA INFECTION CASE IN MALAYSIA
KOTA KINABALU, 12 December, 2016 - The Ministry of Health Malaysia (MOH)

has received a report of the first local transmission of Zika virus infection case in the
country yesterday. The patient is a 51 year old Kadazan Dusun male, residing in Taman
Public Jaya Likas, Kota Kinabalu, Sabah. The patient has been reported to have con-
tracted a fever since last week. He then sought for medical attention from the Luyang
Health Clinic on the 5th of December 2016. He was immediately referred to Queen
Elizabeth Hospital (QEH) 2 when he experienced increasing body temperature, muscle
aches and diarrhoea. The test results from QEH 2 laboratory revealed that the blood
and urine samples of the patient were tested positive for Zika.
It is suspected that the Zika infection is from a local source of contagion as the patient
says that he has not travelled overseas in the past year. There is a possibility that he
was bitten by an infected Aedes mosquito in Sabah.
MOH has taken immediate steps to conduct fogging in Likas, and its surrounding
areas. Besides that, pamphlets containing information on methods of eliminating Aedes
breeding sights are being disseminated at public areas such as clinics, hospitals, and
malls. People are also advised to avoid dark clothing and wear long sleeves and pants
to avoid getting bitten by mosquitoes. Applying mosquito repellent is also advised
when doing outdoor activities.Since Zika can be passed through sex from a person
infected with this virus, it is advisable for couples to have refrain from having sex with
their partner who has travelled to a Zika infected country. Another alternative is to use
a condom during sexual intercourse.
It is highly recommended for anyone experiencing unusual fever, rash, joint pain,
red eyes, muscle pain, headache, or vomiting to get themselves tested at the nearest
hospital. For futher inquiries, please contact the Ministry of Health at 088-266755 (for
Sabah), 082-556577 (for Sarawak) or 03-8776688 (for Peninsular Malaysia).
DATUK DR (insert name here)

Minister of Health, Malaysia
###
145
ONE HEALTH MANUAL
Example 2:
UNTUK SIARAN SEGERA
KENYATAAN AKHBAR
KETUA PENGARAH KEMENTERIAN KESIHATAN MALAYSIA
KES KEMATIAN REMAJA AKIBAT VIRUS INFLUENZA (H1N1)
HULU LANGAT, 25 Mac 2017 - Seorang remaja bernama Ali bin Abdullah, berumur
15 tahun telah dibawa ke sebuah hospital swasta oleh kedua ibu bapanya pada 23 Mac
2017 apabila mengalami kesakitan badan melampau yang bermula dua hari sebelum
itu. Ibu bapanya juga memaklumkan kepada pihak hospital yang anak mereka men-
galami sakit kepala dan batuk selama seminggu tetapi mereka hanya menganggap ini
sebagai sakit biasa dan tidak membawa anak mereka ke hospital lebih awal. Remaja
tersebut dirujuk ke Hospital Hulu Langat dengan kadar yang segera. Malangnya beliau
meninggal semalam, 24 Mac 2017 pada pukul 10.00 malam. Pakar perubatan yang
merawat remaja tersebut mengesahkan bahawa remaja tersebut didapati meninggal
akibat jangkitan virus H1N1.
Guru Besar sekolah remaja tersebut, bernama Puan Lim Ah Ling telahpun memak-
lumkan kepada Pejabat Kesihatan Hulu Langat yang kehadiran pelajar sekolah telah
jatuh sebanyak 25% pada minggu lepas. Ibubapa para pelajar melaporkan kepada pihak
sekolah yang anak mereka mengalami batuk yang serius. Berikutan daripada kejadian
ini, Pejabat Kesihatan Daerah Hulu Langat akan menjalankan pemeriksaan kesihatan di
kawasan kediaman dan sekolah remaja tersebut dalam masa terdekat.
Ia adalah penting untuk mengingatkan orang ramai bahawa seperti mana lain-lain virus
influenza bermusim yang lain, virus H1N1 merebak melalui cecair (droplet) batuk atau
bersin mereka yang dijangkiti. Orang awam boleh dijangkiti jika menyentuh objek atau
permukaan yang dicemari virus H1N1 ini dan seterusnya menyentuh hidung atau mulut
mereka.
Insiden wabak H1N1 pernah berlaku di Kajang pada tahun 2014 yang mana hampir
15% daripada penduduknya dijangkiti virus tersubut. Ketika itu, Kementerian Kesi-
hatan cepat bertindak untuk memperkenalkan langkah-langkah kawalan kepada pen-
duduk di kawasan tersebut. Melalui pendidikan seperti kepentingan membasuh tangan
dan menutup mulut dengan tisu apabila batuk ataupun bersin, penghindaran daripada
jangkitan yang lebih melus berjaya dilakukan.
Memandangkan langkah-langkah ini pernah dilakukan dengan jayanya, langkah-lang-

kah pencegahan ini akan diperkenalkan semula untuk mengharungi masalah H1N1 di
kawasan Hulu Langat. Penutupan sekolah hanyalah langkah terakhir sekiranya masalah
jangkitan telah menjejaskan keseluruhan fungsi sekolah. Pengasingan sosial oleh murid
146
APPENDICES
atau guru yang menunjukkan gejala dengan tidak menghadirkan diri ke sekolah adalah
efektif bagi mengekang penularan jangkitan ini.
Jika terdapat sebarang kecemasan atau pertanyaan hubungi;

Hospital berdekatan atau Institut Respiratori HKL ditalian
03-89468051 atau Hotline 03-89468151
Datuk Dr. (letakkan nama di sini)

Menteri Kesihatan Malaysia
###
147
INDEX
Confirmatory Test, 49
A Clinical Wastes, 54
Agent, 30 Communication, 102
Attack Rate, 38, 73 Chief Ministers, 104
Avian Influenza, 41 Confusion, 104
Antimicrobial Susceptibility, 52 Chronology, 107
Analytical Epidemiology, 69
Attributable Risk, 74 D
Case Control Study, 70 Disciplinary, 8
Cohort Study, 70 Interdisciplinary, 8
Anxiety, 102 Multidisciplinary, 8
Transdisciplinary, 8
B Descriptive Epidemiology, 36
Biosecurity, 21 Diagnostic Test, 47
Brucellosis, 41 Disinfection, 59
Biosafety, 49 Disseminate, 103
Biotyping, 52 Designate, 104
Bio-Hazardous, 54 Director General, 104
Businesses, 102 Disease, 106
Brochures, 105 Outbreak, 106
C E
Chronic Carrier, 30 Epidemic Curve, 39
Contact, 30 Economic, 102
Contamination, 30 Emerging Disease and Surveillance
Team (ESR), 103
Carrier, 30
Case Definition, 33
F
Suspected, 36
Probable, 36 Farming, 102
Confirmed, 36
Case Finding, 40 G
Characterization, 49 Generation Time, 30
148
Point Source Outbreak, 39 Identification, 107
Continuous Common Source
Outbreak, 40 J
Propagated Outbreak, 40
Journalists, 104
Genotypic, 52
L
H
Laboratory, 31
Herd Immunity, 30
Based Surveillance, 31
Human Exposure, 35
Based Data, 46
Possible Exposure, 35
Confirmed Surveillance
Probable Exposure, 36 Information, 46
Exposed, 36 Diagnosis, 35
Host, 30 Investigation, 46
Hypothesis, 68 Involvement, 49
Developing, 68 Response, 46
Evaluating, 69 Techniques, 46
Refining, 75 Testing, 32
Health Care Worker, 35 Laboratory Diagnosis, 35
Humanistic, 104 Probable Diagnosis, 35
Confirmatory Diagnosis, 35
I Leptospirosis, 37
Infectious Diseases, 2
Challenges Posed by, 2 M
Influenza Pandemic Preparedness Manhattan Principles of the Wildlife
plan, Malaysian, 3 Conservation Society, 4
Objectives, 3 Medical waste, 54
Isolation, 4 Ministry of Health, 103
Institute of Medicine Report, 5 Ministry of Primary Industries, 103
Immunogenicity, 30 Media, 104
Incubation Period, 30 Miscommunication, 104
Index Case, 30
Infection, 30 N
Infectivity, 30 Nipah Virus, 3
Incidence, 38
Irrational, 104
149
O Paradigm, 27
One Health, 4, 5 Resources Required, 27
Communication and Technology, 13 Outbreak Management, 9
Competencies, 15, 125-126 Activities of Veterinary and Human
Health Sectors, 23
Concept, 6
Alert Management Team, 21
Definition and Scope, 5
Animal Diseases Crisis
Disease Surveillance, 13
Management Committee, 21
Education and Training, 14-15 Components, 9
Governance, 16 Framework, 10
History, 5 Plan for Animal Health Sector, 21
Infrastructure, 12 Plan for Health Sector, 20, 122
Leadership, 11 Protocol, 22
Manhattan Principles, 4 Rapid Action Team (Veterinary), 21
Milestones and Timelines, 118-120 Rapid Assessment Ream
Origin of the Term, 4 (Human Health) 20
One World One Health, 4 Rapid Response Team
One Medicine, 5 (Human Health) 20
Outbreak, 22
Outcomes from Adopting One, 7
Coordinators, 22
Health Paradigm, 7
Protocol, 22
Paradigm, 4
Team and Members, 22
Plans, Issues and Challenges of
putting One Health into Core Teams, 24
practice, 9-15 Core Team Advisors, 24
Relationships, 12 Core Team Skills, 24
Transdisciplinary Approach, 8 Terms of Reference, 25, 26
Way Forward, 16,17 Odds Ratio, 74
Zoonoses Outbreak Investigation Outburst, 102
based on One Health Paradigm, 7 Organism, 128
Outbreak Investigation, 8
Steps, 8, 121
P
Planning for, 122
Pandemic Prevention and Prepared-
Pre-Outbreak Preparations, 20-28 ness, 2
Materials required for Field Phases, 3
Investigation, 25 Strategic Actions and Goals, 2-3
Preparations based on One Health Primary Case, 30
150
Pathogenicity, 30 Secondary Attack Rate, 39
Prevalence, 38 Serology, 49
Pre analysis, 47 Serological, 49
Phage Typing, 52 Serotyping, 49
Phenotypic, 52 Screening, 49
Plasmodium Knowlesi, 63 Social, 102
Public Health Services,103 Speculations, 102
Podcasts, 105 Source, 103
Posters, 105 Specimen, 128
Political, 106
Press Statement, 106 T
Turnaround Time, 47
R Tourism, 102
Reservoir, 30 Transparent, 102
Relative Risk, 73 Trust, 103
Rumours, 102 Technologies, 105
Receiver, 103
Radio, 104 V
Virulence, 31
S
SARS, 2 W
Outbreak 2003, 2 Websites, 105
Lessons Learnt from Outbreak, 2 West Nile Outbreak, New York City
1999: 123-124
Storage, 14
Secondary Case, 31
Z
Surveillance, 31
Zoonotic Disease, 31
Laboratory-Based, 31
Core Team Advisors, 24
Mandatory Notification, 31
Clinical-based (Sentinel/National/
Syndromic), 31
Community-Based, 31
Active and Passive, 31
Susceptible Host, 31
Suspect, 31
151
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One Health Manual: On Handling Zoonotic Disease Outbreaks in Malaysia

Book · January 2017

Abdul Rashid Khan Rukman Awang Hamat

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Syafinaz Amin Nordin Andrew Kiyu

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All rights reserved.

First Print 2017

Perpustakaan Negara Malaysia Cataloguing-in-Publication Data

Chief Editor, Abdul Rashid Khan,

CHAPTER TOPIC PAGES

Introduction One Health Manual 1

1 Preparations for an Outbreak 19

2 Establish and Verify Diagnosis 29

4 Developing, Evaluating and Refining 67

5 Implementation of Control Measures 85

6 Communication During Outbreak 101

I am confident that by following the recommendations in this Manual, we will improve

DATUK DR. NOOR HISHAM BIN ABDULLAH

Veterinary Services, play an essential role in the development and implementation of

DATO’ DR KAMARUDIN MD ISA

PROFESSOR DR MOHD HAIR BEJO

PROF DR ABDUL RASHID KHAN

Department of Veterinary Services Universiti Kebangsaan Malaysia

AAHL - Australian Animal Health Lab

Dr Khebir bin Verasahib, MD, DAP&E, MPH (Epid)

Associate Professor Dr Rukman Awang Hamat, MBBS, MPATH

Dr Ramlan bin Mohamed, PhD

Assoc. Prof Dr Razitasham Safii, MBBS, M. Comm Health

Dr. Moniza Waheed, B Comm, MA, PhD

Dr Andrew Kiyu, MBBS, MPH, DrPH, AM, FACE

Dr Khebir bin Verasahib, MD, DAP&E, MPH (Epid)

Dr Rozanah Asmah Abu Samad, DVM, PhD

Dr Azizah Darus, DVM

Dr Badrul Hisham b Abd Samad, MBBS, MPH, MEE

Dr Sarah Dadang Abdullah, DVM, MSc, PhD

Prof Dr Abdul Rashid Khan MBBS, M HSc, PhD

Dr Khebir bin Verasahib, MD, DAP&E, MPH (Epid)

Dr Rozanah Asmah Abu Samad, DVM, PhD

Dr Azizah Darus, DVM

Dr Badrul Hisham b Abd Samad, MBBS, MPH, MEE

Dr Sarah Dadang Abdullah, DVM, MSc, PhD

Dr Rosnah Ismail, MBBS, PgDip.OH, MPH, DrPH

Dr Ahmad Filza Ismail, MD, M Comm Med, Certificate in Aerospace Medicine,

Dr Nurul Syuhada Bt Zainal Abidin, DVM

Dr Fairuz Amran, MD, M Path

Associate Professor Dr Rukman Awang Hamat, MBBS, MPATH (Medical

Associate Professor Dr Syafinaz Amin Nordin, MBBS, MPATH (Medical

Dr Taznim Begam binti Mohd Mohidin, PhD

Associate Professor Dr Ariza Adnan, MBBS, M Path, FAMM

Dr Mohammad Saffree Jeffree MD, M. Community Medicine (OH UKM),

Dr Hayati binti Kadir @ Shahar, MBBch. BAO, M. Comm. Health

Dr Akma Binti Ngah Hamid, DVM, MSc.

Dr Sylvia Daim, BSc., MSc., PhD

Dr. Zainol Ariffin bin Pawanchee, MD, MPH

Dr. Yahasmida Yaacob