Principles of Infectious Disease Epidemiology PDF
Principles of Infectious Disease Epidemiology PDF
Principles of Infectious Disease Epidemiology PDF
This outline is provided as an aid to the student. It contains only the basic content of
the module. To view the supporting material such as graphics, examples, etc. please
see the module itself.
I. INTRODUCTION
A. What is the Purpose of Epidemiology:
• to better understand the burden and causes of health problems in human
populations, and
• to make changes that decrease risk and improve health.
D. Epidemiology has been used to study these conditions and many more:
• West Nile Virus infections
• Sexually transmitted diseases and HIV
• Surgical wound infections
• Hip fractures
• Childhood malnutrition
• Pertussis (whooping cough)
• Schizophrenia
E. Epidemiology can help us identify and understand the factors that influence
the emergence, severity, and consequences of health problems. Examples
include:
• tobacco use and lung cancer
• physical activity and heart disease
• diet and longevity
• lead exposure and developmental disabilities
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• seat belt use and motor vehicle injuries/deaths
• childhood vaccine initiatives and child mortality
• statin drugs and outcomes of atherosclerotic heart disease
F. Infectious diseases:
• Are caused by micro-organisms
• Are transmitted to humans from other humans, animals or the environment
• Usually follow recognizable patterns of symptoms, timing, etc.
• Evolve over time as new organisms emerge and human behavior and
environments change
Epidemiology is, thus, the study of what is upon the people. In modern terms, it is the
science of the distribution of disease and its determinants (causes).
Epidemiology is also a process that uses the facts at hand as clues to point to new
knowledge and solutions. Epidemiologists have been called “disease detectives” and
“medical sleuths” for this reason.
B. Three key terms are used to describe basic patterns of infectious disease
occurrence. The terms are defined by the American Public Health Association (APHA)
as:
Endemic: The habitual presence of a disease within a given geographic area; may also
refer to the usual prevalence of a given disease within such an area.
Epidemic: The occurrence in a community or region of a group of illnesses of similar
nature, clearly in excess of normal expectancy, and derived from a common or from a
propagated source.
Pandemic: A worldwide epidemic.
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Endemic disease levels are measured by ongoing surveillance systems. Some
fluctuations usually occur.
The transition from endemic to epidemic can happen in days, weeks, months, or
even years, depending on the disease. It may be hard to tell when the shift begins.
There are parallel terms referring to disease patterns in animals that may affect
humans:
Zoonosis: An infection or an infectious disease transmissible under natural conditions
between vertebrate animals and man (APHA).
Enzootic: “Endemic” among animal populations
Epizootic: “Epidemic” among animal populations
The natural history of a disease is a description of how that disease “behaves” and what
factors affect its incidence and distribution. Here is a partial list of such factors:
1. Biological
2. Geographic
3. Nutritional
4. Meteorological
5. Social
6. Cultural
7. Religious
8. Behavioral
9. Economic
10. Historical
11. Political
12. Technological
Example:
“The Epidemiology of Measles” includes:
Factor Example
Causative organism Measles virus
Host Humans
Mode of transmission Airborne droplets and direct contact with secretions
Incubation period About 10 days, range 7-18 days from exposure
Period of From a few days before onset of illness to 4 days after the
communicability appearance of the rash
Usual symptoms Fever, conjunctivitis, coryza, cough and blotchy red rash
Complications Otitis media, pneumonia, croup, diarrhea and encephalitis
Mortality rate 2-3 per 1,000 cases in USA; 3-5% in developing countries
Epidemiologic methods were used to compile most of this information.
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III. EVOLUTION OF EPIDEMIOLOGY
Human beings have always sought to understand and explain the occurrence of
disease and death.
A. Supernatural Causation
• Throughout most of human history, people believed in the supernatural as the cause
of illness.
• Individuals and communities who became ill were thought to have angered the gods
or spirits, or to be victims of their enemies’ magic.
• Such beliefs are still held today, even in otherwise modern societies.
B. Environmental Explanations
• Hippocrates was the first to suggest that disease is caused by environmental
elements, around 400 B.C.E.
• From 400 B.C.E. until the mid-19th century, many theories were developed to explain
infection.
• Most of these theories were based on the concept of miasmas. Contagious matter
was thought to create a gaseous form, a miasma, which spread infection through the
atmosphere.
C. Host Factors
• Edward Jenner, in 1796, introduced the idea of host resistance to explain why some
people were immune to smallpox.
• Peter Panum, in 1846, took this idea further when he studied measles in the Faroe
Islands. The islanders had not been exposed to measles in 70 years, and many
otherwise healthy adults died.
• By contrast, in mainland Denmark all were exposed to measles in childhood, and
adult deaths from this disease were rare.
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• Snow’s first step was to gather information about the cholera patients
in the area, and record their residence or place of work.
• He developed a spot map that showed the distribution of cases in
relation to the water pumps.
• Snow investigated all the pumps in the area.
• One pump was so grossly contaminated that people had
avoided its use.
• One pump was in an out-of-the way location, and therefore not
used much.
• Many of the cholera cases were clustered around the Broad
Street Pump.
• When Snow checked with the families of the cholera victims, he
confirmed that they all used the Broad Street Pump.
• Snow showed that by studying the distribution of cases, a source of
infection could be found that explained the pattern. He then took
action to stop the epidemic, by having the pump handle removed.
b. Snow did more pioneering work during another cholera outbreak in 1854.
• This outbreak affected several areas of London that depended on
water hauled in by wagon.
• Two companies, the Southwark and Vauxhall (S&V) Company and
the Lambeth Company, did the hauling.
• Some districts were served mostly by S&V, other districts mostly by
Lambeth, and some districts were served by both.
• Snow compared the number of cholera deaths in the various districts.
• Snow realized that the raw numbers of deaths could not tell him
much.
• If some districts had many more people than others, they couldn’t
really be compared.
• So he collected population figures from the most recent census and
calculated cholera death rates per 1,000 people.
• The rates paint a very clear picture.
• The death rate was 22 times higher in the districts served only by
S&V, compared with those served only by Lambeth.
• Further investigation showed that both companies were drawing their
water from the Thames River.
• However, S&V pulled water from a point just downstream from a
major sewer outlet, while Lambeth drew theirs upstream from the
outlet.
• Snow had shown conclusively that water could serve as a vehicle for
transmitting infection. He also showed that humans could intervene, in
this case by changing the location of the S&V water intake.
2. William Farr, the father of modern vital records, was another important figure
in the development of epidemiology. His contributions include:
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• establishing the first registry of births and deaths in the 1830s.
• advancing population-based surveillance.
• distributing reports that led to public health interventions.
Example: Mortality in Liverpool, 1843. The median age of survival in Liverpool in 1843
was 6 years, compared with an average of 45 in the rest of England. This revelation led
to policy and law changes to improve sanitation.
4. Modern Epidemiology
b. The disease agent, the host, and the environment interact dynamically to produce
disease. All three of these are constantly changing:
• Disease agent: Microorganisms adapt to changing conditions, including
human control efforts such as antibiotics.
• Host: Human populations are constantly growing and moving as people
age, travel, and migrate into new environments.
• Environment: Changes occur locally and globally, both naturally and
through human intervention.
(i) Disease Agents: There are many “agents” of disease and disabilities,
including:
• nutritional components such as vitamin deficiency diseases and obesity.
• physical forces such as fire, radiation, and chemicals.
• biological agents such as bacteria and viruses.
In this course, however, we will be focusing on biological agents that will be
covered more fully in other segments of the course.
(ii) Host Factors: Some host factors that influence susceptibility to disease are:
Sex
Race
Age
Occupation
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Nutrition
Heredity
Marital status
Socioeconomic status
Religious and social customs
Immunization history
Previous history of disease
Examples:
1) Some foodborne diseases, such as salmonella, are highly dependent on
environmental factors such as cross-contamination and cooking/holding temperatures.
2) The spread of measles is influenced by immunization status, but also by housing
conditions and nutritional status.
3) Disease history is a big factor with some diseases, such as hepatitis A, that confer
lifetime immunity after infection.
4) Many other diseases can cause repeated infections in the same individual, for
example gonorrhea, shigellosis and malaria.
5) Some diseases are transmitted to humans only through arthropod vectors such as
mosquitoes, ticks or lice.
• These disease organisms may have complex lifecycles that pass through
several different hosts.
• For example, the spirochete that causes Lyme Disease is transmitted to
humans from certain ticks, but its lifecycle includes rodents and large
mammals such as deer.
• Vectors are subject to agent, host and environmental factors too.
Epidemiology gives us tools to learn about how these factors interact to produce a
particular disease in a particular population. Good epidemiology is most critical when
investigating an outbreak or the emergence of a new disease - some of the most
important tasks of the field epidemiologist.
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A team approach is almost always used in epidemiologic investigations. The range of
experts needed depends on the disease and the setting, but usually includes:
• Epidemiologists
• Medical professionals (physicians, nurses)
• Laboratory scientists
• Statisticians
• Environmental specialists
Summary
Epidemiology is a set of tools for understanding the burden and causes of health
problems in human populations, so that we can make changes that decrease risk and
improve health.
Epidemiology can help us identify and understand the factors that influence the
emergence, severity, and consequences of health problems.
Human beings have always sought to understand and explain the occurrence of
disease and death. The modern approach to epidemiology has developed within the
past 150 years.
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PRINCIPLES OF INFECTIOUS DISEASE EPIDEMIOLOGY
This outline is provided as an aid to the student. It contains only the basic content of
the module. To view the supporting material such as graphics, examples, etc. please
see the module itself.
I. INTRODUCTION
Module II is designed to prepare public health workers to meet the following objectives:
1. Describe the six major components of the infectious disease process
2. Demonstrate understanding of the concepts of the infectious disease
spectrum
In order for infection and disease to occur in an individual, a process involving six
related components must occur. This process has been referred to as the “Chain of
Infection.” The six steps or “links” in the chain are:
• Etiologic agent
• Reservoir
• Portal of Exit
• Mode of Transmission
• Portal of Entry
• Susceptible Host
In this module, we will examine each of these links and some other important concepts
that help us understand infectious disease transmission. To stop the spread of disease,
one or more of these links must be broken.
A. Etiologic Agents
There are seven categories of biological agents that can cause infectious diseases.
Each has its own particular characteristics. The types of agents are:
1. Metazoa
2. Protozoa
3. Fungi
4. Bacteria
5. Rickettsia
6. Viruses
7. Prions
1. Metazoa are multicellular animals, many of which are parasites. Among the
diseases they cause are:
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a. Trichinellosis, also called trichinosis, caused by an intestinal roundworm
transmitted through undercooked meat.
b. Hookworm, transmitted through feces-contaminated water and soil. Infestation
can cause chronic anemia that often results in retarded mental and physical
development of children.
c. Schistosomiasis, caused by a blood fluke and transmitted through
contaminated water. Symptoms are related to the number and location of
eggs in the human body, and may involve the liver, intestines, spleen, urinary
tract, and reproductive system.
2. Protozoa are single-cell organisms with a well-defined nucleus. Some of these are
human parasites. Examples of diseases cause by protozoa include:
a. Malaria, a mosquito-borne disease that is one of the top three infectious
diseases in the world (along with tuberculosis and HIV).
b. Giardiasis, an infection of the upper small intestine that causes a diarrheal
illness. Outbreaks can be difficult to control, especially in child care settings
c. Toxoplasmosis, transmitted to humans from cats and undercooked meat.
When this systemic disease infects a pregnant woman, it can cause the death of
the fetus.
d. Pneumocystis carinii pneumonia or PCP, which is often fatal, especially in
people with compromised immune systems such as those infected with HIV.
3. Fungi are nonmotile, filamentous organisms that cause diseases that can be very
difficult to treat. Some examples important to public health are:
a. Histoplasmosis, transmitted by inhaling dust from soil that contains bird
droppings. The severity varies widely, with the lungs the most common site of
infection.
b. Candidiasis, transmitted by contact with human patients and carriers. This
fungus causes lesions on the skin or mucous membranes, including “thrush” and
vulvovaginitis. Symptoms can be severe in immunocompromised people.
4. Bacteria are single-celled organisms that lack a nucleus. They are responsible for a
wide range of human diseases, including:
a. Tuberculosis, a chronic lung disease that is a major cause of disability and
death in many parts of the world.
b. Staphylococcal disease, which can affect almost every organ system.
Severity ranges from a single pustule of impetigo, through pneumonia, arthritis,
endocarditis, etc., to sepsis and death.
c. Chlamydia and gonorrhea, the most widespread sexually transmitted
diseases.
d. Tetanus and diphtheria, two diseases that were once major public health
problems but are now well controlled through immunization.
d. Other vaccine-preventable diseases caused by bacteria are:
• Pertussis
• Haemophilus influenzae type b (Hib)
• Pneumococcal disease.
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5. Rickettsia are a genus of bacteria usually found in the cells of lice, ticks, fleas and
mites. They are smaller than most bacteria and share some characteristics of viruses.
Diseases cause by rickettsia include:
a. Rocky Mountain Spotted Fever, a tick-borne systemic disease that can be
hard to diagnose and that leads to death in 3-5% of US cases.
b. Typhus, a louse-borne rash illness with a high case-fatality rate that has
occurred historically in poor living conditions brought on by war and famine.
6. Viruses are very small, consisting of an RNA or DNA core and an outer coat of
protein. They can reproduce and grow only inside of living cells. Many viral illnesses
are significant to public health, including:
a. Influenza, a respiratory illness that contributes to development of pneumonia
and occurs in annual epidemics during the winter months
b. HIV (human immunodeficiency virus), that causes Acquired Immunodeficiency
Syndrome (AIDS). This severe, life-threatening pandemic disease has spread
worldwide within the past 20-30 years.
c. Rabies, that is spread to humans from animal bites or scratches. Rabies is
almost always fatal in humans but is preventable by a vaccine.
d. Measles, mumps, rubella, and poliomyelitis are all well controlled in the US
through immunization.
7. Prions are infectious agents that do not have any genes. They seem to consist of a
protein with an aberrant structure, which somehow replicates in animal or human tissue.
Prions cause severe damage to the brain. Diseases associated with prions include:
a. CWD, chronic wasting disease of mule, deer and elk;
b. BSE, bovine spongiform encephalopathy in cows; and
c. CJD, Creutzfeld-Jacob disease in humans.
[
B. Reservoirs
The next essential link in the chain of infection is the reservoir, the usual habitat in
which the agent lives and multiplies. Depending upon the agent, the reservoir may be:
• humans,
• animals, and/or
• environment
When working with any disease agent, it is important to learn about its usual
reservoir(s).
1. Human Reservoirs
There are two types of human reservoirs, acute clinical cases and carriers.
a. Acute clinical cases are people who are infected with the disease agent and
become ill.
• Because they are ill, their contacts and activities may be limited.
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• They are also more likely to be diagnosed and treated than carriers
are.
b. Carriers, on the other hand, are people who harbor infectious agents but are
not ill.
• Carriers may present more risk for disease transmission than acute
clinical cases, because their contacts are unaware of their infection,
and their activities are not restricted by illness.
• Depending on the disease, any of the following types of carriers may
be important:
Incubatory carriers
Inapparent infections (also called subclinical cases)
Convalescent carriers
Chronic carriers
Incubatory carriers are people who are going to become ill, but begin
transmitting their infection before their symptoms start. Examples:
measles: a person infected with measles begins to shed the virus in nasal
and throat secretions a day or two before any cold symptoms or rash are
noticeable. Many other diseases also have an incubatory carrier phase.
Most notably, HIV infection may be present for years before the person
develops any symptoms.
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Convalescent carriers are people who continue to be infectious during and
even after their recovery from illness. This happens with many diseases.
Example: Salmonella patients may excrete the bacteria in feces for
several weeks, and rarely even for a year or more. This is most common
in infants and young children. Treatment with inappropriate antibiotics
may prolong the convalescent carrier phase.
Chronic carriers are people who continue to harbor infections for a year or
longer after their recovery. Example: the chronic carrier state is not
uncommon following hepatitis B infection, whether or not the person
became ill, and may be lifelong. The risk of developing chronic hepatitis B
depends on the person’s age at infection. About 90% of infants infected at
birth become chronic carriers of the disease, compared with only 1-10%
infected after age 5. That is why it is so important to give hepatitis B
vaccine to newborns.
2. Animal Reservoirs
Animal reservoirs of infectious agents can be described in the same way as human
reservoirs. They may be
• acute clinical cases, or
• carriers.
Depending upon the disease, different carrier phases may be important in transmission.
3. Environmental Reservoirs
Plants, soil and water may serve as the reservoir of infection for a variety of diseases.
• Most fungal agents (mycoses) live and multiply in the soil.
Examples:
The organism that causes histoplasmosis lives in soil with high organic
content and undisturbed bird droppings.
The agents that cause tetanus, anthrax and botulism are widely distributed
in soil.
The agent of Legionnaire’s Disease lives in water, including hot water
heaters.
C. Portal of Exit
The next link in the chain of disease transmission is the portal of exit, the route by
which the disease agent may escape from the human or animal reservoir. While
many disease agents have only one portal of exit, others may leave by various portals.
The portals most commonly associated with human and animal diseases are:
• Respiratory
• Genitourinary
• Alimentary
• Skin
Superficial lesions
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Percutaneous
• Transplacental
1. Respiratory: This is the route of many disease agents that cause respiratory
illnesses such as the common cold, influenza, and tuberculosis. It is also the route
used by many childhood vaccine-preventable diseases, including measles, mumps,
rubella, pertussis, Haemophilus influenzae type b (Hib), and pneumococcal disease.
This is the most important portal and the most difficult to control.
3. Alimentary: The alimentary portal of exit may be the mouth, as in rabies and other
diseases transmitted by bites. More commonly, disease agents are spread by the other
end of the intestinal tract. These are referred to as enteric diseases. In general, enteric
diseases may be controlled through good hygiene, proper food preparation and sanitary
sewage disposal. Examples include:
• Hepatitis A
• Salmonella, including typhoid
• Shigella
• Cholera
• Giardia
• Campylobacter
4. Skin: Skin may serve as a portal of exit through superficial lesions or through
percutaneous penetration.
• Superficial skin lesions that produce infectious discharges are found in
smallpox, varicella (chickenpox), syphilis, chancroid, and impetigo.
• Percutaneous exit occurs through mosquito bites (malaria, West Nile virus) or
through the use of needles (hepatitis B and C, HIV).
D. Mode of Transmission
A mode of transmission is necessary to bridge the gap between the portal of exit from
the reservoir and the portal of entry into the host. The two basic modes are direct and
indirect.
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examples are sexually transmitted diseases and enteric diseases such as shigella,
giardia and campylobacter. Contact with soil may lead to mycotic (fungal) diseases.
• Animate mechanisms involve vectors. Flies may transmit infectious agents such
as shigella in a purely mechanical way, by walking on feces and then on food.
Mosquitoes, ticks or fleas may serve as reservoirs for the growth and
multiplication of agents, for example in malaria or Lyme disease.
E. Portals of Entry
The portal of entry into the host is usually the same as the portal of exit from the
reservoir.
In some diseases, however, the exit and entry portals may differ. Example:
staphylococcal bacteria may escape from one person’s respiratory tract to infect
another person’s skin lesion. If that person is a foodhandler, the staphylococcal
bacteria may escape from the infected skin lesion, contaminate food where it can
incubate, and cause “food poisoning” in people eating the food.
F. Susceptible Host
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The last essential component in the chain of infection is the susceptible host.
Susceptibility is affected by:
• Genetic factors
• General resistance factors
• Specific acquired immunity
2. General resistance factors include many body functions that we take for granted.
Intact skin and mucous membranes help us resist disease. So do the gastric acid in our
stomachs, the cilia in our respiratory tracts, and the cough reflex.
• Artificial immunity may be acquired through the use of vaccines, toxoids and
immune globulins.
Active immunity: Receiving a vaccine or toxoid stimulates “active”
immunity, since the recipient responds by producing his/her own
antibodies.
Passive immunity: Receiving an antitoxin or immune globulin confers
“passive” immunity, essentially by borrowing the antibodies of other
people. Passive immunity lasts for only a short time, while active
immunity usually lasts much longer, even for a lifetime.
By now, you probably appreciate the complexity of the factors that work together to
cause the transmission of infectious agents. The impact of disease agents on human
host populations is also a bit complex.
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If a large number of individuals are equally exposed to an infectious agent, they do not
all respond in the same manner. In fact, there may be a broad range of responses:
• Some do not become infected at all
• Some become infected but develop no symptoms
• Some become infected and develop mild or moderate symptoms
• Some become infected and develop severe symptoms
• Some die as a result of their infection
Part of this variation is due to the capacity of the agent to produce disease. Infection of
a healthy adult population with salmonella is likely to result in mostly inapparent or mild
cases, with only a few people with more severe symptoms and very few deaths. On the
other end of the spectrum, infections with rabies almost always result in severe illness
and death.
Part of the variation is due to differing levels of resistance of the hosts. If measles is
introduced into a highly immunized population, then most individuals do not become
infected. If measles is introduced into an unimmunized, nutritionally deprived
population, the spectrum shifts toward severe symptoms and a high death rate.
The existence of the infectious disease spectrum can make it challenging to find out the
extent of transmission in a particular population. Most cases with inapparent or mild
symptoms will never be discovered or reported, since these people will not seek health
care. So when moderate or severe cases are reported, they may represent the “tip of
the iceberg.”
Another challenge is posed by the fact that many diseases look alike. A variety of
agents may produce essentially similar clinical syndromes. For example, the signs and
symptoms of tuberculosis, other mycobacteria, and histoplasmosis may be the same.
However, effective treatment and control measures are very different for these three
diseases. This is why laboratory identification of the specific disease agent is so
important in any epidemiological investigation.
Summary
In order for infection and disease to occur in an individual, a process involving six
related components must occur. This process has been referred to as the “Chain of
Infection.”
To stop the spread of disease, one or more of these links must be broken.
The impact of disease agents on human host populations is complex. If a large number
of individuals are equally exposed to an infectious agent, there may be a broad range of
responses, from no infection at all to death.
Because of the infectious disease spectrum, it can be challenging to identify the extent
of transmission in a particular population.
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Many diseases share the same signs and symptoms, so laboratory studies are
important to identify the specific disease agent.
10
PRINCIPLES OF INFECTIOUS DISEASE EPIDEMIOLOGY
This outline is provided as an aid to the student. It contains only the basic
content of the module. To view the supporting material such as graphics,
examples, etc. please see the module itself.
I. INTRODUCTION
Module III is designed to prepare public health workers to meet the following
objectives:
• Define public health surveillance and describe its components
• Demonstrate understanding of the purposes of surveillance and how it relates
to public health action
• Describe the two basic forms of surveillance and the most common sources of
surveillance information
• Demonstrate knowledge of how to evaluate and improve surveillance systems
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Whatever form it takes, surveillance is essential to the practice of public health,
especially for infectious disease prevention and control.
The concept of public health surveillance grew out of the earlier practice of
medical surveillance, which is still done in some situations.
Medical Surveillance Public Health Surveillance
Close observation of people Always looks at populations,
exposed to a communicable rather than individuals
disease to detect symptoms early
and provide treatment or require
isolation
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o Is a new disease or health concern emerging?
3. Set priorities for the use of resources (time, expertise, technology and
money)
o To what activities should staff time and expertise be directed?
o How much money should be spent on a particular problem?
o Do we need to respond immediately to investigate and control a
problem in our community?
4. Assist in planning, implementing and evaluating public health
interventions and programs
o To which populations should we target interventions or control
measures?
o Are new prevention programs needed?
o How effective are our programs and control measures in reducing
disease occurrence?
5. Evaluate public policy
o Are current rules or laws protecting the public?
o Are new rules, laws, ordinances or other policies needed?
6. Generate questions and hypotheses that provide direction for
further research
o Why is this disease occurring in this specific population?
o Is the disease the result of an environmental exposure?
o Is this group of people especially susceptible to the disease?
o Has the disease agent changed somehow?
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o Or a disease that previously occurred mainly in one group of people
may move to another
• Follow long-term trends and patterns of disease.
o Many diseases ebb and flow in cycles that vary by season or over
several years.
o Knowing this may help us interpret the current situation.
• Identify changes in agents and host factors.
o Many infectious agents change over time. (E.g., shifts in
predominant salmonella serotype by year, antibiotic resistant
gonorrhea].
o Data from laboratory scientists who monitor these characteristics can
be used to direct vaccine production, treatment, and other
prevention and control measures.
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control when the incidence goes down. This was done in the 1980s, and
the result was an upsurge in tuberculosis cases.
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5. Evaluate Public Policy
Public policies, such as laws, ordinances, and institutional policies, are
important public health interventions. Surveillance information can help
identify needed policy changes.
EXAMPLES
a. Immunization requirements have evolved as disease transmission patterns
change.
• School immunization rules were implemented and enforced to reduce
outbreaks of measles and rubella in schools.
• As more children entered childcare centers and homes, the transmission
of vaccine-preventable diseases among preschool children increased. In
the 1980s, immunization requirements for childcare attendance were
developed and incorporated into licensure requirements. Outbreaks in
licensed childcare settings have since become rare.
b. Standards for food protection are codified as state rules and local
ordinances. Inadequacies in these food codes were identified in the 1990s
through surveillance data, and the rules were strengthened.
• Required cooking temperatures for beef were changed because of E. coli
O157:H7 outbreaks.
• The rules on the transport and handling of fresh eggs were changed
because of outbreaks of Salmonella enteritidis.
A. Legal Requirements
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o Healthcare providers can only share such information if the proper
legal framework is in place to authorize it.
o Under the federal Health Insurance Portability and Accountability Act
(known as HIPAA), public health agencies have the right to collect
personal health information if state law authorizes them to do so.
o This right is known as the “public health exemption” from HIPAA.
Without this provision, public health surveillance would be much
more difficult.
• Missouri law requires the state Department of Health and Senior Services
(DHSS) to designate which diseases and conditions must be reported to public
health authorities and who must report (Revised Statutes of Missouri 192.020)
http://www.moga.mo.gov/statutes/c192.htm.
• Through the Code of State Regulations, local public health agencies are
designated to receive such information as well (19 CSR 20-20.010-20.080).
In the large metropolitan areas, there may also be local ordinances and rules
pertaining to disease reporting.
• Some key provisions of the Missouri reporting rules include:
a. Mandated Reporters. The following individuals and agencies are
required to report diseases:
o Physicians
o Physician’s assistants
o Nurses
o Hospitals
o Clinics
o Laboratories
o Other private or public institutions providing diagnostic testing,
screening or care to any person with any reportable disease or
condition
o Persons in charge of a public or private school, summer camp or
child or adult care facility
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o 1A: Selected high priority diseases, findings, or agents that occur
naturally, from accidental exposure, or as the result of a bioterrorism
event.
o 1B: Instances, clusters, or outbreaks of unusual disease or
manifestations of illness and clusters or instances of unexplained
deaths which appear to be the result of a terrorist act or the intentional
or deliberate release of biological, chemical, radiological, or physical
agents, including exposures through food, water, or air.
o 1C: Instances, clusters, or outbreaks or unusual, novel, and/or
emerging diseases or findings not otherwise named in this rule,
appearing to be naturally occurring, but posing a substantial risk to
public health and/or social and economic stability due to their ease of
dissemination or transmittal, associated mortality rates, or the need for
special public health actions to control.
2. Diseases, findings, or agents that shall be reported within one (1) day of
first knowledge or suspicion.
o 2A: Diseases, findings, or agents that occur naturally, or from
accidental exposure, or as a result of an undetected bioterrorism event.
o 2B: Diseases, findings, or adverse reactions that occur as a result of
inoculation to prevent smallpox.
3. Diseases, findings, or agents that shall be reported within three (3) days of
first knowledge or suspicion.
4. Diseases or findings that shall be reported weekly.
5. Diseases or findings that shall be reported quarterly.
c. Flexibility.
Missouri’s rules include the provision that any unusual outbreak of
disease must be reported.
o Allow healthcare providers to share information even if the
specific disease or condition isn’t on the official list.
o Is especially important for emerging infections, or outbreaks of
unknown cause including potential bioterrorist incidents.
• The mandated reporting rule has evolved over time and will continue to
do so.
o New categories of reporters may be added as the healthcare system
changes.
o New diseases may be added as they emerge into public health
importance, and old ones may be removed if they are no longer
significant threats.
o Sometimes old diseases take on new significance, as happened when
smallpox was added back to the list because of its potential use as a
bioterrorist agent.
There are many sources of data for surveillance purposes. Some of the main
ones are:
• Morbidity reports (mandated disease reports, laboratory test results, hospital
and clinic data)
10
• Mortality reports (death certificates, medical examiner data)
• Surveillance systems for disease indicators (for example, animal rabies test
results, bird and horse West Nile Virus test results)
• Environmental data (laboratory test results on water, milk, and food supplies)
• Student and employee data (for example, school or work absenteeism)
• Drug and biologic utilization (for example, prescriptions and sales figures on
over-the-counter medications)
• Population-based surveys (for example, Behavioral Risk Factor Surveillance
System, National Health and Nutrition Examination Survey)
C. Forms Of Surveillance
1. Passive surveillance.
o Reports are initiated by the information source, such as a
physician, laboratory, or hospital.
o Traditional mandated disease reporting is based on this approach.
o The public health agencies put a system in place and then wait for
reports to come in by telephone, fax or mail.
The standard form for reporting in Missouri is the
CD-1 Form. Click here to view the form:
http://www.dhss.mo.gov/CommunicableDisease/index.html
o Passive reporting is the backbone of surveillance for many
diseases, because it is easy and inexpensive for the public health
agency.
o However, it can be cumbersome for the reporters, and
opportunities to report are often missed.
o Systems that depend solely on passive reporting usually
undercount disease incidence.
2. Active surveillance.
o The public health agency initiates contact with the reporting
sources on a regular basis (daily, weekly, etc.).
o Contacts may be made by telephone, electronically, or through
on-site record review by public health agency staff.
o With active surveillance, reports are solicited even if they indicate
zero disease activity for that time period.
11
o Active surveillance often takes the form of sentinel surveillance.
This can involve regular contact with a selected set of sentinel
sites or providers, or using animals or insect vectors as “sentinels”
for a particular disease.
o Electronic medical records systems have opened up many new
possibilities for active surveillance.
Example: DHSS is developing a process that will allow hospital
laboratories to submit electronic files of test results directly into
the Missouri Health Surveillance Information System (MOHSIS)
computer system. The data will then be processed and alert
messages will be sent to local public health agency staff. This is
expected to reduce the data entry workload and increase the
completeness, accuracy and timeliness of laboratory reports.
Modern surveillance practice combines active and passive methods to get the
most complete picture possible.
Example:
Influenza surveillance in Missouri includes the following information:
• Summary case counts collected by local public health agencies (LPHAs)
from sentinel healthcare providers. This information is compared with
reporting from previous time periods to track the seasonal epidemic.
• Weekly reports from healthcare providers (34 healthcare providers in 2005)
who participate in CDC’s US Influenza Sentinel Provider Surveillance
Network (US ISPSN). They report the number of patients they have seen
that week, broken down by age group, and how many of them showed
influenza-like illness. This information is compared to a national baseline.
• Results of laboratory tests performed by the State Public Health Laboratory,
and of more specialized testing performed on some isolates by the CDC
laboratory (passive surveillance). This information is used with other test
results from around the world, to determine influenza vaccine strains for
the coming year.
All of these sources of surveillance information are combined into a weekly
report posted on the DHSS website.
Example:
12
For vector-borne diseases, some combination of active and passive
surveillance of both humans and animals may be needed. Surveillance for
arboviruses such as West Nile Virus (WNV) is a good example. In Missouri,
arboviral surveillance includes humans, horses, birds and mosquitoes.
• Dead birds are collected and submitted to DHSS by (LPHAs) for laboratory
testing. This may be the only early warning that local spread of the WNV
virus is occurring.
• Mosquito trapping is the best tool to quantify the intensity of virus
transmission in an area. In 2004 over a dozen LPHAs (covering 59% of the
Missouri population) trapped mosquitoes, collected them, and either
shipped them for testing or tested them locally and provided the results to
DHSS.
• Equine (horse) surveillance is a passive system that relies on
veterinarians to report. Equine WNV is rare now that a vaccine is in wide
use.
• Active surveillance for human cases. During the peak of WNV activity
in 2001-2003, sentinel healthcare providers were contacted by LPHAs at
least two times per week.
• Passive surveillance for human cases. This is mostly laboratory-
based, with the majority of reports coming from the State Public Health
Laboratory.
13
o Every reportable disease has an official case definition that is used to
determine whether a case should be “counted” in the surveillance
system.
o The case definition is usually a combination of symptoms and laboratory
test results, and is defined by CDC for nationally notifiable diseases.
o Case definitions reflect different levels of certainty. There are
definitions for suspect vs. probable vs. confirmed cases.
o Each case reported to the system should be evaluated in relation to the
case definition, as a basic quality assurance mechanism.
If the analysis shows that the incidence of a disease is different from what you would
expect, then further investigation should be done.
• For some diseases, this is true even if the number of cases is small.
Example: even a single case of a potential bioterrorist agent (such as
anthrax) or a vaccine-preventable disease (such as measles) should be
investigated.
• There are several possible explanations for changes in surveillance data.
Explanations that should be considered include (but are not limited to ):
o An outbreak
o An intentional exposure (such as a bioterrorist attack)
o A newly emerging infection
o Improved diagnosis (new laboratory test, increased physician awareness)
o Increased awareness of the disease and/or the need to report it
o A gradual increase or decrease in incidence due to environmental or
population changes, or changes in the disease agent
o A disease following its natural seasonal or “secular” (years-long) cycle
o Changes in the surveillance system (new data collection system, loss of
a reporting source, addition of a new source, change in case definition,
etc.)
• The only reason to carry out public health surveillance is to use the
information to improve the health of the public.
• Many of the ways this is done were discussed earlier in the section, “Why Do
We Do Public Health Surveillance?”
16
o Does it contribute to an improved understanding of the public health
implications of diseases (numbers of people affected, severity of illness,
burden of hospitalization, etc.)?
o Can it help determine that a disease that was previously thought to be
unimportant is actually important?
o Does it provide data for performance measurement, including health
indicators used for assessing community needs and evaluating health
programs?
• It may be helpful to list and describe the actions taken as a result of analysis
and interpretation of the data from the system, and to identify who has used
the information to make decisions and take actions.
17
♦ Representativeness. Does the system accurately describe the occurrence of the
disease over time and its distribution in the population by place and person?
Or is it “skewed” toward certain age groups, ethnic groups, geographic areas,
or healthcare providers?
♦ Timeliness. How quickly does the system receive and process information?
This can be assessed by looking at the speed between steps in the system.
♦ Stability. How reliable is the system (reliability is the ability to collect, manage,
and provide data properly without failure). Is the system operational when it
is needed?
By evaluating these attributes, we can identify ways to improve the system. For
more complete information about these criteria and recommended methods
for evaluation of surveillance systems, go to
www.cdc.gov/mmwr/preview/mmwrhtml/rr5013a1.htm.
18
PRINCIPLES OF INFECTIOUS DISEASE EPIDEMIOLOGY
Please note: Because of formatting constraints, the formulas in the outline may
not appear in correct mathematical format, however, they do appear correctly in
the course module.
I. INTRODUCTION
Module IV is designed to prepare public health workers to meet the following
objectives:
• Define the most common statistical frequency measures used in infectious
disease epidemiology
• Construct a frequency distribution
• Calculate and interpret the following statistical measures:
Ratios
Proportions
Incidence rates, including attack and secondary attack rates
Prevalence
Mortality rates
Relative risk and odds ratio
• Choose and apply the appropriate statistical measures
1
• The most common statistical measures used in field epidemiology are
“frequency measures,” which are simply ways of counting cases and
comparing their characteristics. In contrast with statistics used in
epidemiological research, frequency measures are relatively easy to
calculate and use.
• When we collect data about disease cases, we must put them in some
kind of order. The most basic way to do this is to organize a “line listing”.
Example: http://www.dhss.mo.gov/CDManual/CDsec30.pdf (scroll down to
page 77).
• A line listing is actually a simple database, in which each row represents a
case of the disease we are investigating. Each column contains
information about one characteristic, called a “variable.”
• Look at the data in Table 1
Table 1
Neonatal Listeriosis, General Hospital A, Costa Rica, 1989
Culture Symptom Delivery Delivery Admitting
ID Sex Date Date DOB Type Site Outcome Symptoms
CS F 6/2 6/2 6/2 Vaginal Del Rm Lived Dyspnea
CT M 6/8 6/8 6/2 C-section Oper Rm Lived Fever
WG F 6/15 6/15 6/8 Vaginal Emer Rm Died Dyspnea
PA F 6/15 6/12 6/8 Vaginal Del Rm Lived Fever
SA F 6/15 6/15 6/11 C-section Oper Rm Lived Pneumonia
HP F 6/22 6/20 6/14 C-section Oper Rm Lived Fever
SS M 6/22 6/21 6/14 Vaginal Del Rm Lived Fever
JB F 6/22 6/18 6/15 C-section Oper Rm Lived Fever
BS M 6/22 6/20 6/15 C-section Oper Rm Lived Pneumonia
JG M 6/23 6/19 6/16 Forceps Del Rm Lived Fever
NC M 7/21 7/21 7/21 Vaginal Del Rm Died Dyspnea
Abbreviations:
Vaginal = vaginal delivery
Del Rm = delivery room
Oper Rm = operating room
Emer Rm = emergency room
o How many of the cases were male? We can easily pick out that
information because there are only a few cases.
o But with a larger database, we cannot get that information at a
glance. We must summarize variables into tables called
“frequency distributions.”
• A frequency distribution
o shows the values a variable can take, and
o the number of people or records with each value.
2
o Example: suppose we are investigating an outbreak in an
elementary school. We could construct a frequency table that
shows how many of the ill children were in each classroom.
Table 2
Distribution of cases by classroom
Brown School, Missouri, June 2005
Classroom Number of Cases
101 25
102 43
103 32
104 0
105 8
106 2
Total 110
• Variables
o The values of a variable may be
numbers (for example, number of tacos eaten);
an ordered numerical scale (for example, age); or,
categories (for example, ill or well), called a “nominal scale”
because the categories are named.
o In epidemiology we often deal with variables that have only two
categories, like alive or dead, ill or well, did or did not eat the potato
salad.
o Any of these types of data may be summarized in a frequency
distribution (See Table 3, which shows a variable with only two
possible values).
Table 3
Influenza vaccination status among residents
Nursing Home A, Missouri, December 2005
Vaccinated? Number
Yes 76
No 125
Total 201
3
IV. RATIOS, PROPORTIONS AND RATES
o In this formula, x and y are the two quantities that are being
compared.
o The formula shows that x is divided by y.
o 10ⁿ is a constant that we use to transform the result of the division
into a uniform quantity.
o The size of 10ⁿ may equal 1, 10, 100, 1000 and so on depending
on the value of n.
Example:
10² = 10 x 10 = 100
10³ = 10 x 10 x 10 = 1000
10⁵ = 10 x 10 x 10 x 10 x 10 = 100,000
A. Ratios:
• A ratio is used to compare the occurrence of a variable in two different
groups.
• These may be two completely independent groups, or one may be
included in the other.
• For example, we could compare the sex of children attending an
immunization clinic in either of the following ways:
1) female or 2) female
male all
4
B. Proportions:
• The second type of ratio, in which x is part of y, is also called a proportion
(as in the previous (female/all) example).
• Proportions are usually expressed as percentages.
Examples
Independent x and y:
During the first 9 months of national surveillance for eosinophilia-myalgia
syndrome (EMS), CDC received 1,068 case reports that specified sex;
893 cases were in females, 175 in males. Here is the method for
calculating the female-to-male ratio for EMS.
Thus, there were just over 5 female EMS patients for each male EMS
patient reported to CDC.
x included in y:
Based on the same data, here is the method for calculating the
proportion of EMS cases that were male.
4. Reduce the fraction so that one value equals 1. Divide the smaller
number by the larger number: 175/1,068 = 0.16/1
5
5. Proportions are usually expressed as percentages, so the value of the
constant (10ⁿ) = 10² = 100:
0.16 X 100 = 16 (16%)
C. Rates:
• The third type of frequency measure used with two-category
(dichotomous) variables is a rate.
• Rates have the added dimension of time. Rates measure the occurrence
of an event in a population over time.
• The basic formula for a rate is:
To summarize:
o All three of these frequency measures are calculated in basically
the same way. In practice, we use:
a ratio to compare two independent groups,
a proportion to compare one group with a larger one to
which it belongs, and
a rate to measure an event in a population over time.
o Ratios, proportions, and rates are used in infectious disease
epidemiology to describe morbidity (disease) and mortality
(death).
6
V. MORBIDITY FREQUENCY MEASURES
A. Incidence Rates
• Incidence rates are the most common way of measuring and comparing
the frequency of disease in populations.
• Incidence is a measure of risk.
• When Population A has a higher incidence of a disease than Population B,
we can say that Population A has a higher risk of developing the disease
than Population B. If it is a lot higher, we could say that Population A is a
high-risk group for that disease.
• Table 4 shows the three types of incidence rates we will study, along with
their formulas. We will discuss each of these in more detail.
Table 4
Frequently Used Measures of Morbidity
Expressed per
Measure Numerator (x) Denominator (y) Number at Risk
(10ⁿ)
Incidence # new cases of a Average population Varies:
Rate specified disease during time interval 10ⁿ where
reported during a n = 2, 3, 4, 5, 6
given time interval
Attack Rate # new cases of a Population at start Usually a
specified disease of the epidemic percentage:
reported during an period 10ⁿ where
epidemic period n=2
Secondary # new cases of a Size of contact Usually a
Attack Rate specified disease population at risk percentage:
among contacts of 10ⁿ where
known cases n=2
7
1) Incidence
The basic incidence rate (sometimes called just incidence) is a measure of the
frequency with which a disease occurs in a population over a period of time. The
formula for calculating an incidence rate is:
Incidence Rate = new cases occurring during a given time period X 10ⁿ
population at risk during the same time period
Disease incidence rates imply a change over time, from health to disease. So
the period of time must be specified. For surveillance purposes this is usually
one calendar year, but any time period may be used as long as it is stated.
Example
In 2003, 335,104 new cases of gonorrhea were reported among the US
civilian population. The 2003 mid-year US civilian population was estimated to
be 290,788,976. For these data we will use a value of 10⁵ for 10ⁿ. We will
8
calculate the 2003 gonorrhea incidence rate for the US civilian population using
these data.
1. Define x and y : x = new cases of gonorrhea in US civilians during 2003
y = US civilian population in 2003
2. Identify x, y, and 10ⁿ: x = 335,104
y = 290,788,976
10ⁿ = 10⁵ = 100,000
3. Calculate (x/y) x 10ⁿ:
2) Attack Rate
An attack rate is a specific type of incidence rate. It is calculated for a narrowly
defined population observed for a limited time, such as during an outbreak. It is
usually expressed as a percentage, so 10ⁿ equals 100.
For a defined population (the population at risk), during a limited time period:
Attack Rate = # of new cases among the population during the period X 100
population at risk at the beginning of the period
Example
Of 75 persons who attended a church picnic, 46 subsequently developed
a gastrointestinal illness. To calculate the attack rate of GI illness we first
define the numerator and denominator:
9
x = Cases of GI illness occurring within the incubation period
for GI illness among persons who attended the picnic = 46
y = Number of persons at the picnic = 75
Then, the attack rate for GI illness is 46 x 100 = 61%
75
In this example, we could say that among persons who attended the
picnic, the probability of developing GI illness was 61%, or the risk of
developing GI illness was 61%.
• Attack rates are usually calculated several times during the course of an
outbreak investigation. The first time, early in the outbreak, the attack rate
might be calculated as follows:
Attack Rate = # of new cases in the community during the period X 100
the population of the community
Secondary = # cases among contacts of primary cases during the period X 100
Attack Rate total number of contacts
10
o In some situations, contacts in other settings may be investigated
(for example, residents of a homeless shelter, or people who work
in a specific building). The calculation is done in the same way as
for household contacts.
Example
Seven cases of hepatitis A occurred among 70 children attending a
childcare center. Each infected child came from a different family. The
total number of persons in the 7 affected families was 32. One incubation
period later, 5 family members of the 7 infected children also developed
hepatitis A. We will calculate the attack rate in the childcare center and
the secondary attack rate among family contacts of those cases.
1. Attack rate in childcare center:
x = cases of hepatitis A among children in childcare center = 7
y = number of children enrolled in the childcare center = 70
A rate ratio compares the rates of disease in two groups that differ by
demographic characteristics or exposure history. The rate for the group of
primary interest is divided by the rate for a comparison group.
Rate ratios may be calculated for incidence rates (including attack rates) or for
mortality rates, discussed later.
Example
The Association of Interested Persons held their annual conference during
the first week in June. There were two events: a dinner meeting on
Wednesday evening (75 attendees), and a luncheon awards ceremony
on Thursday at noon (60 attendees). Twenty (20) of the 75 Wednesday
dinner participants subsequently developed signs and symptoms of
gastrointestinal illness; 5 of the 60 luncheon participants became ill.
Calculate the rate ratio to help determine which event may have been the
source of the illness. The rate ratio is calculated as follows:
11
1. Calculate the attack rate for the dinner meeting:
x = number of ill persons attending the dinner meeting
y = number of persons attending the dinner meeting
attack rate = (x/y) x 100 = (20/75) x 100 = 27%
2. Calculate the attack rate for the luncheon:
x = number of ill persons attending the luncheon
y = number of persons attending the luncheon
attack rate = (x/y) x 100 = (5/60) x 100 = 8%
3. Calculate the rate ratio:
Rate ratio = rate for group of primary interest x 1 = (27/8) x 1 = 3.4
rate for comparison group
The dinner meeting attendees were 3.4 times more likely to become ill
than those who attended the luncheon.
Now that you know how to calculate and use each type of morbidity rate, you
have mastered some important tools for investigating infectious diseases.
Prevalence = all new and pre-existing cases during a time period X 10ⁿ
population during the same time period
• Point Prevalence: For example, we may want to find out the prevalence
of TB in Community A today. To do that, we need to calculate the point
prevalence on a given date.
o The numerator would include all known TB patients who live in
Community A that day. That information could be determined from
a TB case registry.
o The denominator would be the population of Community A that day.
12
o Example: A review of patients reported to the tuberculosis registry
in Midville revealed that as of July 1, 2005 there were 35 cases that
had not yet completed therapy. The most recent population
estimate for Midville was 57,763. The prevalence of TB in Midville
on July 1, 2005 was:
___35____ X 10,000 = 6.1 per 10,000 people
57,763
o Point prevalence is useful in comparing different points in time to
help determine whether an outbreak is occurring. In this case, we
could also calculate point prevalence of TB for July 1, 2004, July 1,
1995 or other relevant points of comparison.
13
2. Incidence during the 12-month period:
x = number of new positives during the 12-month period = 35 – 25 = 10
y = population at risk = 5,000 – 25 (already infected) = 4,975
(x/y) x 10ⁿ = 10/4,975 x 1,000 = 2 per 1,000
Prevalence is based on both incidence (risk) and duration of disease.
High prevalence of a disease within a population may reflect high risk, or it may
reflect prolonged survival without cure. Conversely, low prevalence may indicate
low incidence, a rapidly fatal process, or rapid recovery.
The most commonly used values for 10ⁿ are 1,000 and 100,000.
14
• For example, the mortality rate attributed to HIV among 25-to-44-year-olds
in the US in 1987 was:
The last two types of frequency measures we will study are relative risk (also
called risk ratio) and odds ratio. These statistics are used in outbreak
investigations and will be discussed again in the workshop portion of this course.
Table 5
Number of Cases of Disease X by Sex, Smallville, 2004
Disease X
Yes No Total
Female a 46 b 1,438 1,484
Male c 18 d 1,401 1,419
The term “two-by-two” refers to the two variables (sex and disease status),
each with two categories. The outcome (illness or not) is shown at the top
of the table and exposure or risk factor is shown along the left side. Note
the letters assigned to each cell of the table (a-d). They are important in
calculating the risk in each group.
15
Example
Using the data in the table above, we can calculate the relative risk of
Disease X for females vs. males. First, we must calculate the risk of
illness among females and among males:
To calculate the RR for females vs. males, females are considered the
group of primary interest and males are the comparison group. The
formula is:
• We will not teach more about statistical significance in this course, but the
student should be aware that RR is affected by factors such as population
size, and cannot stand alone. Statistical consultation is readily available
from DHSS for the field epidemiologist.
B. Odds Ratio
The RR can only be calculated if incidence data are available. The Odds Ratio
(OR) may be used in situations where we do not have denominator data to
calculate incidence rates.
• The odds ratio is used frequently in case/control studies, which we will
cover in more detail in the workshop portion of this course.
• In a case/control study, ill persons’ characteristics and exposures are
compared with those of well persons (“controls”) selected from the same
population in which the outbreak occurred.
o Example: in an outbreak suspected to stem from exposure to
contaminated food at a restaurant, the ill persons’ food selections
16
could be compared with those of some well people who also ate at
the restaurant the same day. This could be done even if we didn’t
know exactly how many people ate at the restaurant that day.
• A two-by-two table is constructed, just like the one used to calculate RR,
with the same letters (a-d) used to label the cells. The OR is calculated by
multiplying across the cells.
Example:
Table 7
Number of Cases of Disease X by Exposure History, Smallville, 2004
Disease X
Yes No Total
Ate Tuna a 46 b 25 71
Casserole
Didn’t Eat Tuna c 18 d 40 58
Casserole
Odds Ratio = ad
bc
Where
a = number of persons with disease and with exposure of interest
b = number of persons without disease, but with exposure of interest
c = number of persons with disease, but without exposure of interest
d = number of persons without disease and without exposure of interest
So those who became ill were 4.1 times as likely to have eaten the tuna
casserole. We should probably look a little more deeply into the tuna casserole!
We would still need to subject this result to a test of statistical significance (just
like we do with the RR) to judge the probability that the result could have
occurred by chance alone.
17
PRINCIPLES OF INFECTIOUS DISEASE EPIDEMIOLOGY
Portions of this module were adapted from the Centers for Disease Control and
Prevention (CDC) “Principles of Epidemiology, Second Edition, An Introduction to
Applied Epidemiology and Biostatistics, 1998.”
Note: You will need to access the course to view the many examples associated
with this module, as they are not included in this outline.
I. INTRODUCTION
Module V is designed to prepare public health workers to meet the following
objectives:
• Define the three categories of epidemiologic variables
• Identify the three main methods used to organize epidemiologic data
• Correctly interpret graphic presentations of epidemiologic data
• Choose appropriate display methods and formats for specific kinds of
epidemiologic data
1
WHO? Identify individuals and sub-populations at risk of exposure or
transmission
A. Tables
1. In General:
• A table is a set of data, organized into rows and columns.
• Tables are useful for identifying patterns, exceptions, differences
and other relationships.
• Tables also serve as the basis for charts and graphs.
2
• Footnotes that note any data excluded from the analysis
• Clear identification of the source of the data in a footnote
2. Types of Tables
a) One Variable Tables. The simplest form of table has only one
variable. That is the frequency distribution, which was discussed in
Module IV, Statistical Measures.
• To review briefly, in a frequency distribution table, the first column
shows the values (or categories) of a variable, and the second
column shows the number of people or records that fall into each
value or category.
• Often, there is a third column that lists the percentage of persons or
events in each category.
• Sometimes a one-variable table shows the cumulative frequency or
cumulative percent.
3
o Create categories that are mutually exclusive and include all of
the data. For example, if your first category is 0-5, the next one
must start with 6, not 5.
o Use a relatively large number of narrow categories for the initial
analysis, since you can always combine them later.
o Try to use standard groupings if they are available – for
example, age categories used by CDC for a particular disease.
o Create a category for unknowns, since there will usually be
missing information for some of the cases.
B. Charts
1. In General
Charts:
• Are a method of organizing and illustrating data using only one
coordinate.
• Are best used for comparing data with discrete categories.
Several types of charts may be produced using common spreadsheet
software such as Excel.
2. Types of Charts
a) Bar Charts. Bar charts are used to create a visual display of the data
from a table. The bars may be either horizontal or vertical.
4
o The values of the second variable make up segments of the
bars that represent the first variable.
o These charts can be hard to interpret, since only the first
segment rests on a flat baseline.
b) Pie Charts.
• A pie chart is simple and easily understood.
o Very useful for showing the component parts of a single group
or variable.
o The size of the pie “slices” shows the percentage for each
component part of the whole.
o Pie charts are easily generated using spreadsheet software
such as Excel.
5
c) Maps.
o Maps are a very widely used type of chart.
o They are also called geographic coordinate charts.
o Spot maps and area maps are commonly used in field
epidemiology.
• Spot maps use dots or other symbols to show where an event took
place, or where a disease condition exists.
o Spot maps are good for detecting clusters of disease cases.
o However, we must remember that a spot map does not take
into account the size of the population at risk.
o So it does not show the risk of the event occurring in that
particular place.
o A heavy clustering of dots may simply mean that more
people live in that area and therefore more cases appear
there.
C. GRAPHS
1. In General:
• A graph is a way to show numerical data visually, using a system of
coordinates.
• A graph can help us see patterns, trends, aberrations, similarities,
and differences in the data.
• People usually understand and remember the important aspects of
data much more easily from looking at a graph than a table.
• Graph format:
o Most graphs used in epidemiology have two lines, one
horizontal and one vertical.
o The horizontal line is called the x-axis
o The vertical line is the y-axis.
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o The x-axis (horizontal) is used to show the values of the
method of classification, for example, time in years, which is called
the independent variable.
o The y-axis (vertical) is use to show the dependent variable,
usually a frequency measure such as number of cases or rate of
disease.
o Each axis must be clearly labeled and the scale of
measurement marked.
2. Types of Graphs
Here are a few simple rules for constructing arithmetic-scale line graphs:
• Mark off each axis at equal intervals.
• Use a scale on the x-axis that matches the intervals used when
collecting the data (for example, days, weeks, months or years). If
very small intervals were used, combine them into larger ones.
• Make the y-axis shorter than the x-axis, so the graph appears
horizontal.
• Always start the y-axis with 0.
• Pick a range of values for the y-axis that is slightly higher than the
largest number you will be plotting.
• Select an interval size for the y-axis that will give you enough intervals
to show the data in enough detail for your purposes.
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It is very important to use comparable data when making such comparisons. Be
sure the data are comparable with respect to:
• Case definitions
• Level of effort in case-finding and data collection
• Time periods (compare weeks with weeks, months with months etc.)
• Populations (if two populations differ in age distribution or density, this
should be taken into account)
A. Time
1. In General
Variations over time in the frequency of a disease can tell us a lot about
the determinants of that disease in a given population.
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• Many diseases are subject to cyclic changes over time. Diseases
that are strongly influenced by environmental factors may show
seasonal variation.
• Finally, time trends for a disease may simply show erratic change due
to chance variations, sometimes called “noise.” This is true of many
diseases with low endemic levels. It is also a common pattern when
looking at very localized data, since the number of cases may be too
low to exhibit a strong pattern.
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There may or may not be horizontal lines between the
squares
B. Place
• Place is a specific geographic area that can be described by latitude,
longitude and altitude. As used in epidemiology, place:
o May be a street address, city, state, region, or country, or
o May be expressed as a dichotomous, “either-or” variable
such as
urban/rural
domestic/foreign
institutional/non-institutional
lower vs. higher socioeconomic areas
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o Country of origin or of exposure can be important, because
diseases may be imported from endemic areas (for example,
malaria)
• Place comparisons are most useful if we look at the data over time.
Remember, no one point in time can give us all the information we
need.
C. Person
As we learned in Module I, people can be described in terms of many inherited or
acquired characteristics such as:
• Age
• Sex
• Race
• Immune status
• Marital status
• Educational level
Or, they may be described by the circumstances in which they live, such as:
• Social conditions, for example housing
• Economic status
• Environmental conditions
These variables are important since they determine, to a large degree, who is at
the greatest risk of acquiring specific infections.
Our behavior, and therefore our risk of exposure, differs markedly at different life
stages. Examples are the mouthing behavior of toddlers and increased sexual
activity during adolescence and young adulthood.
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Sex can also influence the risk of disease.
For many diseases, both sexes have about the same level of risk. However,
if there is a gender difference in a particular disease it usually means either
males or females had a greater opportunity for exposure. This could be due to
differences in:
• occupation (for example, child care, agricultural work)
• recreational activities (for example, hunting), or
• social behaviors (for example, intravenous drug use)
Summary
Epidemiologic variables are characteristics that can be observed and/or
measured. They may be characteristics of
• time,
• place, or
• person.
Tables, charts and graphs are good tools for organizing epidemiologic data.
They make it possible to identify, explore, understand and present data
distributions, trends and relationships.
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PRINCIPLES OF INFECTIOUS DISEASE EPIDEMIOLOGY
I. INTRODUCTION
• Interviewing people to elicit information is a key skill for any field epidemiologist.
• When investigating a disease case or outbreak, we must help people “open up” and
give us accurate information.
• Success in disease control often depends on the ability to develop trust and rapport,
and to aid people in recalling what has happened.
Because interviewing is a skill that requires practice, this module will present only the
“basics.” You will have the opportunity to practice during the Workshop portion of this
course.
Field epidemiologists may interview a wide variety of people in the course of their work,
such as:
• Health professionals reporting a disease case or outbreak
• People diagnosed with, or suspected to have, an infectious disease
• People who may have come into contact with someone with an infectious
disease
• People who may have been exposed to a disease source (for example, a food
establishment, specific food product, or water supply)
• Workers involved in a suspected disease outbreak, such as food service, health
care or childcare workers
Interviews may be done in person or by telephone and may take place in all kinds of
settings, such as:
• homes
• hospitals
• workplaces
• schools or childcare centers, or even
• “on the street” - anywhere a disease investigation takes us.
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Example:
A hospital laboratory reports a case of Salmonella in a young woman who is
hospitalized.
Interview #1:
The field epidemiologist calls the hospital’s records department to get information to
complete the initial CD-1 report.
Interview #2:
• The field epidemiologist:
o visits the hospital and interviews the patient, using a standard enteric
disease investigation form.
o finds out, through this interview, that the patient had lunch with a friend
two days before she became ill.
o finds out that the friend has been mildly ill with nausea, diarrhea, and
fever.
Interview #3:
• The field epidemiologist:
o calls the friend and completes an enteric disease investigation interview.
o finds out that the friend works in a childcare center, and has continued to
work throughout her illness.
o arranges for the friend to be tested for salmonellosis.
The basic purpose of an epidemiologic interview is to get information that can help
prevent the spread of disease. Interviews may:
• Obtain complete data for disease reporting and analysis
• Provide “clues” that lead to hypothesis development
• Identify the source and/or connections between disease cases or outbreaks
• Help prevent the development of disease in those potentially exposed
• Help prevent the complications of untreated disease in those already infected
The goals of an interview vary with the type of interview. Some common goals are:
• To get honest, complete and accurate information
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• To educate the person being interviewed about the disease and its treatment
• To motivate the person to assist in identifying additional people at risk and
preventing the spread of infection
• To reduce the risk of the person spreading the disease
Trust
To gain the trust of the interview subject, rapport must be established by
• discussing common interests.
• showing the person that this is not just a job, and that you truly care about their
health and the health of those around them.
• explaining the goal of the interview and how it will benefit the person and
others.
Confidentiality
• Confidentiality is a very important principle in public health work.
• If the person has concerns about whether the information will be kept
confidential, they may be reluctant to provide information.
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o A contact must never be told the name or identity of the person who
named them as a contact (or given other information that could lead to
identifying the source, such as specific times, places, etc.).
o Information must be shared only with other health professionals who
have a need to know in order to perform the investigation.
Effective interviewing requires good communication skills. There are three components
of effective communication:
1. Non-verbal communication
2. Verbal communication
3. Effective listening
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When interviews are done by phone, of course, non-verbal communication is less
important. However, your tone of voice and the pace of your speech can convey some
of the same messages that non-verbal cues such as posture convey in person.
2. Verbal communication refers to the way we organize and present the words we
use. Some tips for good verbal communication include:
• Brevity: Be brief and to the point.
• Primacy: Say the most important things first, to help the person remember
them.
• Organization: Ask your questions and present your messages in a logical
and sequential manner. It is always best to use a prepared format for an
interview.
• Appropriate educational level: Remember that many people cannot
understand technical terms or complicated sentences. The average reading
level among the public is 4th to 6th grade. Use familiar terms and avoid
“talking down.”
• Clarification: Always give the person the opportunity to ask clarifying
questions. If they don’t understand what you are asking, they cannot give
accurate information.
• Repetition: Repeat important topics to help the person understand and
remember the message. You may also ask the person to repeat the
information.
• Specificity: Be explicit. Do not raise irrelevant points or “beat around the
bush,” or the message will be lost.
VI. OBJECTIVITY
There is one other key ingredient of a good interview. The interviewer must remain
objective and try to elicit accurate information. To do this:
• Don’t anticipate the answers - let the person speak for him- or herself.
• Go back over any responses that seem inconsistent. For example, when
reconstructing an exposure history, if there are gaps, contradictions or the timing
seems “off,” gently guide the person through the sequence of events again. It
can be hard to remember things that happened days or weeks ago!
• Never “lead” a person to a particular answer, even if you have a strong suspicion
what the answer “should be.” You will only harm the investigation by influencing
the responses.
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• If you sense that the person is hesitant to share some information, concentrate
on making them comfortable. You may need to “back off” and come back to that
subject again later.
• Take some time at the end of the interview to go over your notes and ask any
needed follow-up questions.
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MODULE VII
Outbreak Investigations
A. Overview
• Outbreak investigations should be a collaborative effort, since several tasks requiring
different skills must be done at the same time.
• This list is a summary of the things that need to be considered in any investigation. In
real life, several of these steps may go on at the same time. Their order will vary, and
several of the steps may occur more than once. However, all of these things are
necessary to the successful resolution of an outbreak.
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2. Staff should receive training, including Introduction to Epidemiology, Principles
of Epidemiology and other disease specific courses on investigative procedures.
3. Assemble materials: laboratory kits, forms, reference materials, personal
protective equipment such as gloves and masks.
4. Maintain a current phone directory, including e-mail and Internet addresses, home
addresses and phone numbers of team participants, and key contact personnel
outside the Local Public Health Agency.
5. Maintain adequate local surveillance systems for the early detection of increased
disease incidence.
C. Definitions
An outbreak or epidemic is the occurrence in a community or region of an illness(es) of similar
nature, clearly in excess of normal expectancy, and derived from a common or a propagated
source (19 CSR 20-20.010).
Acute gastroenteritis is an illness with sudden onset characterized by symptoms such as diarrhea,
vomiting, fever, or abdominal cramping.
NOTE: Always consider the possibility of intentional contamination when investigating
an outbreak. If a bioterrorism event is suspected, notify your Regional Communicable
Disease Coordinator and appropriate law enforcement officials immediately.
Introduction
In this case study you will investigate a disease outbreak following the Steps in Disease
Investigation above. For purposes of this exercise, you will be the head of the investigation
team for the Washaw County Health Department (WCHD), and you will work on each of the
steps in order. For each step, you will be given some information describing the current situation
and then asked to describe how you would handle that step. The correct answers will be provided
after each step.
Situation: On June 7, 2002, the WCHD nurse received a call from a person who had attended a
wedding and reception on June 1, 2002 and soon afterward became ill with acute gastroenteritis.
The caller said he knew of several other people who were also ill.
Question: What additional information should you get from the caller?
STEP 2. Determine the extent of the illness. Are there other associated cases?
Situation: You have contacted the local hospital. The Laboratory Director said they had
recently sent five Salmonella isolates from stool cultures to the State Public Health Laboratory
(SPHL) for additional testing. Within the next three days, the SPHL reported that the five
isolates were all Salmonella infantis. One of these patients was the caller who attended the
wedding.
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You have telephoned the Southwest Regional Communicable Disease Coordinator, who
reviewed the surveillance data in the MOHSIS computer system. No other cases of Salmonella
infantis had been reported in the Southwest Region in all of 2002.
a. Question: Should this episode be considered an outbreak? If so, what other activities should
you start?
b. Question: What definition of an outbreak related case would best serve the investigation at
this point?
STEP 3. Learn about the suspected agent—is it transmissible from person to person?
Through the environment (including food or water)?
Situation: By carrying out the activities in the previous steps, the following information was
obtained:
• There were three meals associated with the wedding celebration:
May 31, 2002 Rehearsal Dinner
June 01, 2002 Bridal Brunch (morning)
June 01, 2002 Wedding Reception (7:00 p.m.)
• The bridal brunch was held at a private residence, and was attended by 12 women.
• The rehearsal dinner and the wedding reception were catered by a local catering firm and
held at a convention center. The catering firm is operated out of a home with a separate
kitchen devoted to the business.
• About 30 people attended the rehearsal dinner and 300 attended the wedding reception.
• All of the first five identified cases attended the reception, but only one was at the
rehearsal dinner and none attended the bridal brunch.
a. Question: At this early stage, what would be a reasonable tentative hypothesis about what
may have caused the outbreak?
Clues:
• Formulate a tentative hypothesis based on the time, place, and person associations you
have found so far. This hypothesis will form a basis for the investigation. It is very
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important not to be too narrow in your focus, thereby excluding potentially important
cases or events.
• Develop the hypothesis by interpreting available data to determine:
o Identity of most likely agent(s)
o Most likely source(s) of agent
o Most likely mode by which agent was transmitted.
b. Question: The purpose of the detailed investigation is to gather the information needed to
test your tentative hypothesis. What are the required tests of each component of the hypothesis,
and what information is needed for each?
c. Question: You have developed your hypothesis and determined what information you
will need to gather. How will you gather the information and test your hypothesis?
Situation: You’ve gathered a lot of information. Now you need to develop a more refined case
definition so you can clearly identify the relevant cases and analyze the data. The goal is to
create a case definition that is sufficiently “tight” to include only the people whom you are
reasonably sure had Salmonella infections related to the outbreak.
Question: What elements will you use to formulate your case definition? What is your new,
refined case definition?
STEP 7. Analyze the cases and characterize by time, place, and person.
Situation: The investigation was carried out as planned. With the assistance of the Regional
Communicable Disease Coordinator, the following steps were taken:
• The case definition was used to identify which people were considered to be
“cases.”
• An epidemiologic curve (histogram) was created.
• A case-control study was conducted and attack rates were calculated.
Following are the major findings, grouped again by the three major parts of the hypothesis.
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“nervous diarrhea” before the wedding, and her Salmonella infection actually began
later.
• Sadly, the bride and groom were also reported to be ill. They were not included in the
study because they had left on their honeymoon anyway.
• The common signs and symptoms were diarrhea (100%), cramps (84%), nausea
(52%), fever (52%), chills (44%), and headache (36%).
• There were 24 cases who reported onset time. The mean onset time was 23 hours
after the wedding reception began; the range was 6 to 63 hours.
• Environmental evaluation
o No food remained for testing.
o On June 10, 2002, the convention center in which the reception was held was
inspected and revealed the following:
The tables used for serving food had no cold holding capacity.
Serving tables were not provided with sneeze shields.
The kitchen area was adequately equipped and clean.
o The inspection and evaluation of the caterer’s facility on June 10 revealed the
following:
Foodhandling equipment appeared to be in good working order.
The operation did not have a three-vat sink for proper dishwashing.
All foods served at the wedding reception were to be served cold.
The caterer received uncooked boneless turkey breasts at approximately
10:00 p.m., Wednesday, May 29. They were delivered frozen by the
bride’s family from Smallville, individually vacuum packaged. The
caterer immediately placed the breasts in a tub of water. The caterer
could not remember if the breasts were placed in refrigeration or left on
the counter at room temperature to thaw. The thawed breasts were
cooked in the original vacuum packaging Thursday afternoon, May 30,
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to a temperature of 170°F using a meat thermometer to check cooking
temperature. They were removed from the electric roaster oven and
cooled at room temperature for 1½ to 2 hours. The breasts were then
placed in refrigeration. They were sliced at the caterer’s on a
commercial meat slicer Friday afternoon, May 31. Old food debris was
found on the slicer on June 10, the day of inspection.
The potato salad was prepared on Thursday, May 30, at the caterer’s
with the following ingredients: potatoes, Miracle Whip salad dressing,
mustard, commercially prepared pickle relish, celery, sugar, salt and
pepper.
The pasta salad was prepared at the caterer’s on Thursday, May 30,
with the following ingredients: commercially prepackaged noodles,
oil, vinegar and mustard.
Pre-cooked boneless hams were served, which were shaved and
packaged at two large grocery stores in a nearby town. Unannounced
visits to both stores on June 11, 2002 revealed that the hams were
sliced in the meat cutting departments. Only a single meat slicer was
present in each meat department. During the day, raw and cooked
products were being sliced. The meat slicers were not thoroughly
cleaned and sanitized between the slicing of raw and cooked products.
Raw beef particles were present on both slicers at the time of
inspection. The ambient air temperatures in the meat cutting rooms
were in the mid to upper 70s.
Pre-cooked Hormel brand roast beef was sliced and packaged at a
grocery in a small town in the southern part of the county. The roast
beef was picked up the morning of the dinner and delivered in coolers
to the convention center where the dinner was served. A visit to the
grocery on June 11, 2002, revealed the following: The meat slicer was
used only for precooked prepackaged deli meats. The meat slicer was
clean. The walk-in meat cooler used for storage was 40°F and also
clean.
o On June 10, 2002, a sample of the water supply at the catering establishment
was obtained and analyzed based on Department of Health and Senior Services
standards for drinking water. The water was determined to be unsatisfactory,
with bacteria too numerous to count with coliforms. It was also noted that the
well that supplies the water was located within 50 feet of a hog lot.
b. Question: Referring to the epidemic curve (the histogram you previously downloaded),
is the distribution of the cases compatible with a common exposure at the wedding
reception? Describe how you arrived at your conclusion.
c. Question: Will the information obtained allow an adequate test of each element of the
hypothesis?
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STEP 8. Evaluate the hypothesis and formulate conclusions.
Situation: You now have all available information from the statistical analysis, along with
laboratory data, environmental inspection findings, and other relevant information with which to
evaluate the hypothesis and formulate conclusions.
a. Question: Is the first part of the hypothesis (“This is an outbreak of Salmonella infantis. . .”)
supported well enough by the data that you accept it as true?
b. Question: Is the second part of the hypothesis (“. . . caused by the ingestion of contaminated
foods (or beverages)...”) supported well enough by the data that you accept it as true?
c. Question: Is the third part of the hypothesis (“. . . served at the wedding reception on June
1”) supported well enough by the data that you accept it as true?
Situation: The outbreak was caused by an organism, Salmonella infantis, which causes
gastrointestinal symptoms.
b. Question: How can you determine whether the control measures were effective?
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PRINCIPLES OF INFECTIOUS DISEASE EPIDEMIOLOGY
Note: You will need to access the course to view the examples
associated with this module, as they are not included in this outline.
INTRODUCTION
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discoveries made during the investigation are not lost. They can be used
to design and implement improvements in the surveillance system and
prevention/control measures. Ultimately, this knowledge can help reduce
the risk of similar situations occurring in the future.
I. TITLE
II. SUMMARY
The Summary section should contain all of the key facts that describe
what happened. It should be brief and concise. The information can be
explained and elaborated in other sections of the report.
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Key statistics about the outbreak include:
• Attack rate (if available)
• Hospitalization rate
• Death rate
• Frequency distribution of symptoms
• Median date of exposure
• Median date of onset
• Average incubation period
• Average duration of illness
• Average duration of hospitalization
III. INTRODUCTION
The Introduction can be brief, and should set the scene for the
investigation. It should include:
• Date of initial report
• Agency that received the initial report
• Place and date of the outbreak
• Name and official title of the person submitting the report
IV. BACKGROUND
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V. METHODS
The Methods section should answer the reader’s questions about what
was done, how and by whom. It should include:
• What population was considered to be at risk?
• What and how much data was collected?
• From whom and from how many people were data collected?
• By whom were data collected?
• How were case definition(s) developed and used?
• How was the well comparison group selected, and how
many people were in it?
• How were data collected and analyzed?
o Records reviewed
o People interviewed
o Questionnaires developed and distributed
o Questionnaire reliability and validity
• How were laboratory specimens collected and analyzed?
• What laboratory standards were used?
• What hypotheses were developed (including tentative ones)?
• Where, by whom and how were environmental
inspections done? (including the standards used for the
inspections, for example, the 2000 city ordinance or 1999 state
food code)
VI. RESULTS
The Results section should present all of the results from all of the
methods used, including laboratory testing, interviews and environmental
inspections. The information included in the Summary section can be
presented and explained in more detail here (except for the control
measures and recommendations).
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• a summary of the exposure histories of the persons interviewed
(for example, their food histories)
• results of statistical probability testing
• test results from the environmental samples
• test results from the human specimens
VII. ANALYSIS
This is the place to present what you have learned from the investigation.
It should show your conclusions and interpretations regarding the:
• source of infection
• agent
• reservoir
• mode of transmission
• the group at highest risk
This section should answer the reader’s questions about the measures
taken to control the outbreak:
• What methods were used for outbreak control?
• How were they implemented?
• Where, when and by whom were they implemented?
• How was their effectiveness measured?
• How effective were they?
IX. RECOMMENDATIONS
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X. OTHER OUTCOMES
This is the place to describe what the outbreak, and the efforts to control
it, have done to the population at risk. First, what impact did the
outbreak itself have, including both health and economic consequences?
• Did any individuals have serious complications that will cause long-
term health problems? Was the health care system adversely
impacted by the outbreak, for example by a surge in hospital
admissions?
• Were businesses or institutions affected economically (for example,
by adverse publicity)?
Finally, this is the place to share your other discoveries. Did you learn
something new to science in the course of the investigation? Often,
outbreaks yield new knowledge that needs to be shared with other public
health workers. Examples: new agent, reservoir, vector, temperature
range, novel mode of transmission, unusual symptoms or complications,
etc.
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• Transmission of Salmonella via public drinking water. The water
was cross-contaminated from an abandoned industrial water tower
with birds roosting in it. This led to a new water tower inspection
program in the Department of Natural Resources.