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Case study

An outbreak of hepatitis E in a Rural Area of Islamabad, Pakistan in April-May 2019: a teaching case-study

An outbreak of hepatitis E in a Rural Area of Islamabad, Pakistan in April-May 2019: a teaching case-study

Nosheen Ashraf1,&, Wasif Malik1, Mumtaz Ali Khan1, Jamil A. Ansari1, Aamer Ikram1


1National Institute of Health, Islamabad, Pakistan



&Corresponding author
Nosheen Ashraf, National Institute of Health, Islamabad, Pakistan




Hepatitis E is an acute viral infection caused by the Hepatitis E virus (HEV). An estimated 20 million HEV infections occurred worldwide and 3.3 million became symptomatic. The transmission route of the virus is fecal-oral via water contamination. This disease is prevalent in low- and middle-income countries with no proper sanitation system, water supply, and hygiene and health services. Sporadic cases of Hepatitis E occur throughout the year in Pakistan. Pakistan is a highly endemic area for Hepatitis E and small epidemics occur in different cities of the country. HEV is transmitted when sewage water mixes and contaminates the water supply pipelines due to broken pipelines or open drainage systems. Anti-HEV IgM and IgG antibodies are the serological markers to confirm the cases, also HEV´s RNA is a useful epidemiological marker. The incubation period of the virus ranges from 2 to 10 weeks, with an average of 40 days. The goal of this case study is to develop student´s capabilities in investigating outbreaks. This case study will help students learn about the methods of outbreak investigation and the features of an outbreak which could help them analyze surveillance data in order to find the causes of an outbreak. The case study will also help students determine the environmental factors leading to disease outbreaks, the significance of creating public awareness about an outbreak and the necessary preventive measures, multi-sectorial involvement towards preventing disease outbreaks in the community, and creating contingency action plans for outbreaks.



How to use this case study    Down

General instructions: this case study should be used as adjunct training material for novice epidemiology trainees to reinforce the concepts taught in prior lectures. The case study is ideally taught by a facilitator in groups of about 20 participants. Participants are to take turns reading the case study, usually a paragraph per student. The facilitator guides the discussion on possible responses to questions. The facilitator may make use of flip charts to illustrate certain points. Additional instructor´s notes for facilitation are coupled with each question in the instructor´s guide to aid facilitation.

Audience: this case study was developed for novice field epidemiology students. These participants are commonly health care workers working in the county departments of health whose background may be as medical doctors, nurses, environmental health officers or laboratory scientists who work in public health-related fields. Most have a health science or biology background.

Prerequisites: before using this case study, participants should have received lectures on disease surveillance and outbreak investigation.

Materials needed: Flash drive, flip charts, markers, computers with MS Excel

Level of training and associated public health activity: Novice - Outbreak Investigation

Time required: 2-3 hours

Language: English



Case study material Up    Down



Competing interest Up    Down

The authors declare no competing interests.



Acknowledgement Up    Down

We wish to acknowledge the Eastern Mediterranean Public Health Network (EMPHNET) for their support to develop this case study. We would also like to acknowledge the team at the National Institute of Health, Islamabad, who conducted the outbreak investigation on which this case study is based.



Annexes Up    Down

Annex 1: the questionnaire (page 1)

Annex 2: the questionnaire (page 2)

Annex 3: Excel sheet (Hepatitis E outbreak all suspected and confirmed cases)

Annex 4: Hepatitis E cases



References Up    Down

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