UNIVERSITY OF THE SOUTHERN CARIBBEAN

Extension and Affiliation programmes with

ANDREWS UNIVERSITY

SCHOOL OF SCIENCES & TECHNOLOGY

Department of Biological Sciences

EPIDEMIOLOGY

LAB MANUAL

Prepared by
Department of Biology
LAB # TOPIC PAGE

1
Infectious Diseases and Epidemiology 3

2. Frequency measures used in Epidemiology 9

3 Micro-Epidemiology and Index Case 18

4. Immune Defense & Infectious Disease 21

5. Field Epidemiology Investigation 27

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 Lab 1: Infectious Diseases and Epidemiology

Objectives:
1. Describe the portals of entry and relate these to the routes of transmission for
common infections
2. Describe the important components in controlling an epidemic.
3. Analyze the source, transmission, and potential impact of an epidemic when
provided pertinent data.

Background:

Epidemiology is the study of the spread of disease through a population.

An increase in the prevalence of a disease over a given time, within a specific area or
affecting a particular population, it is considered an epidemic.

Data is collected on the agent, number of cases, the location and history of the disease,
ages involved, contributing factors and other pertinent information.

Analysis of these details provides data to determine whether a vaccine,

chemotherapeutic agent, quarantine, vector control, behavioral changes, or other
precautions may control the disease spread.

Depending upon the morbidity or mortality of the disease, strict measures may have to
be implemented to control it.

One example of these measures are the list of required reportable diseases. The table
on the next page lists the nationally notifiable diseases which must be reported to the
public health department in the United States.

In this lab exercise you will study portals of entry, methods of transmission, and control
of infectious diseases. In addition, using the internet you will examine the CDC’s method
of reporting, tracking and controlling epidemics.

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Page 4 of 34
Procedure:

Exercise A. Portal of Entry

Using infectious diseases listed in table 14.3 on page 2 fill in the table below concerning
information about portals of entry. This table should be turned in before the end of the
Laboratory session.

Portal of Entry Example of a disease using this Methods to prevent the spread
portal of entry of a disease using this portal of
entry.

Skin

Mucous
Membranes

Placenta

Gastrointestinal
Route

Parenteral
Route

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Exercise B. Modes of Transmission
Using infectious diseases listed in table 14.3 on page 2 fill in the table below
concerning information about modes of transmission.
Mode of How does this type of Examples of diseases
Transmission transmission occur, under spread via this mode of
what circumstances? transmission.

Direct contract

Indirect contact

Airborne

Food and
waterborne

Vector

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Exercise C. Examining Epidemics
Fill in the tables below for each of the epidemics stated. Information may be
obtained from your textbook, or credible sources such as Centre for Disease
Control and Prevention (http://www.cdc.gov)

1. Shiga toxin-producing E. coli (STEC)

Name of the etiologic agent causing the epidemic:

Classification:

Brief description of this agent:

Portal of Entry:

Mode of Transmission:

Symptoms:

Treatment:

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Means of Epidemiologic Control:

2. Dengue Fever.

Name of the etiologic agent causing the epidemic:

Classification:

Brief description of this agent:

Portal of Entry:

Mode of Transmission:

Symptoms:

Treatment:

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 Means of Epidemiologic Control:

Reference: 1801 Panorama Dr. - Bakersfield, CA 93305 - (661)395-4011

Last Updated 8/27/2007 ©Janet Fulks

Lab 2: Frequency measures used in Epidemiology

Objectives:
After studying this lesson and answering the questions in the exercises, you will be able to
calculate and interpret the following epidemiologic measures:
1. Ratio
2. Proportion
3. Incidence proportion (attack rate)
4. Incidence rate
5. Prevalence

Background:

Frequency Measures

A measure of central location provides a single value that summarizes an entire distribution of
data. In contrast, a frequency measure characterizes only part of the distribution. Frequency
measures compare one part of the distribution to another part of the distribution, or to the
entire distribution. Common frequency measures are ratios, proportions, and rates. All three
frequency measures have the same basic form:

(Numerator / denominator) x 10n

Recall that:

100 = 1 (anything raised to the 0 power equals 1)

101 = 10 (anything raised to the 1st power is the value itself)

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102 = 10 x 10 = 100

103 = 10 x 10 x 10 = 1,000

So the fraction of (numerator/denominator) can be multiplied by 1, 10, 100, 1000, and so on.
This multiplier varies by measure and will be addressed in each section.

Ratio

Definition of ratio

A ratio is the relative magnitude of two quantities or a comparison of any two values. It is
calculated by dividing one interval- or ratio-scale variable by the other. The numerator and
denominator need not be related. Therefore, one could compare apples with oranges or apples
with number of physician visits.

Method for calculating a ratio

Number∨rate of events ,items , persons , etc∈a group

Number ∨rate of events , items , persons , etc∈another group

After the numerator is divided by the denominator, the result is often expressed as the result “to
one” or written as the result “:1.” Note that in certain ratios, the numerator and denominator are
different categories of the same variable, such as males and females, or persons 20–29 years and
30–39 years of age. In other ratios, the numerator and denominator are completely different
variables, such as the number of hospitals in a city and the size of the population living in that
city.

Proportion
Definition of proportion
A proportion is the comparison of a part to the whole. It is a type of ratio in which the numerator
is included in the denominator. You might use a proportion to describe what fraction of clinic
patients tested positive for HIV, or what percentage of the population is younger than 25 years of
age. A proportion may be expressed as a decimal, a fraction, or a percentage.

Method for calculating a proportion

Number of persons on events witha particular characteristic

n
Total number of persons∨events , of which the numerator is a⊂¿ x 10 ¿

For a proportion, 10n is usually 100 (or n=2) and is often expressed as a percentage.

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Rate
Definition of rate
In epidemiology, a rate is a measure of the frequency with which an event occurs in a defined
population over a specified period of time. Because rates put disease frequency in the perspective
of the size of the population, rates are particularly useful for comparing disease frequency in
different locations, at different times, or among different groups of persons with potentially
different sized populations; that is, a rate is a measure of risk. To a non-epidemiologist, rate
means how fast something is happening or going. The speedometer of a car indicates the car’s
speed or rate of travel in miles or kilometers per hour. This rate is always reported per some unit
of time. Some epidemiologists restrict use of the term rate to similar measures that are expressed
per unit of time. For these epidemiologists, a rate describes how quickly disease occurs in a
population, for example, 70 new cases of breast cancer per 1,000 women per year. This measure
conveys a sense of the speed with which disease occurs in a population, and seems to imply that
this pattern has occurred and will continue to occur for the foreseeable future. This rate is an
incidence rate.

Other epidemiologists use the term rate more loosely, referring to proportions with case counts in
the numerator and size of population in the denominator as rates. Thus, an attack rate is the
proportion of the population that develops illness during an outbreak. For example, 20 of 130
persons developed diarrhea after attending a picnic. (An alternative and more accurate phrase for
attack rate is incidence proportion.) A prevalence rate is the proportion of the population that
has a health condition at a point in time. For example, 70 influenza case-patients in March 2005
reported in County A. A case-fatality rate is the proportion of persons with the disease who die
from it. For example, one death due to meningitis among County A’s population. All of these
measures are proportions, and none is expressed per units of time. Therefore, these measures are
not considered “true” rates by some, although use of the terminology is widespread.

Incidence proportion or risk

Definition of incidence proportion
Incidence proportion is the proportion of an initially disease-free population that develops
disease, becomes injured, or dies during a specified (usually limited) period of time. Synonyms
include attack rate, risk, probability of getting disease, and cumulative incidence. Incidence
proportion is a proportion because the persons in the numerator, those who develop disease, are
all included in the denominator (the entire population).

Method for calculating incidence proportion (risk)

Number of new cases of disease∨injury during specified period

¿ population at start of period

Overall attack rate is the total number of new cases divided by the total population.

A food-specific attack rate is the number of persons who ate a specified food and became ill
divided by the total number of persons who ate that food, as illustrated in the previous potato
salad example.

A secondary attack rate is sometimes calculated to document the difference between

community transmission of illness versus transmission of illness in a household,
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barracks, or other closed population. It is calculated as:

Number of casesamong contacts of primary cases n

x 10
Total number of contacts

Often, the total number of contacts in the denominator is calculated as the total population in the
households of the primary cases, minus the number of primary cases. For a secondary attack rate,
10n usually is 100%.

Incidence rate or person-time rate

Definition of incidence rate
Incidence rate or person-time rate is a measure of incidence that incorporates time directly into
the denominator. A person-time rate is generally calculated from a long-term cohort follow-up
study, wherein enrollees are followed over time and the occurrence of new cases of disease is
documented. Typically, each person is observed from an established starting time until one of
four “end points” is reached: onset of disease, death, migration out of the study (“lost to follow-
up”), or the end of the study. Similar to the incidence proportion, the numerator of the incidence
rate is the number of new cases identified during the period of observation. However, the
denominator differs. The denominator is the sum of the time each person was observed, totaled
for all persons. This denominator represents the total time the population was at risk of and being
watched for disease. Thus, the incidence rate is the ratio of the number of cases to the total time
the population is at risk of disease.

Method for calculating incidence rate

Number of new cases of disease∨injury during specified period

Time each person was observed totaled for all persons

Prevalence
Definition of prevalence
Prevalence, sometimes referred to as prevalence rate, is the proportion of persons in a
population who have a particular disease or attribute at a specified point in time or over a
specified period of time. Prevalence differs from incidence in that prevalence includes all cases,
both new and pre-existing, in the population at the specified time, whereas incidence is limited to
new cases only.

Point prevalence refers to the prevalence measured at a particular point in time. It is the
proportion of persons with a particular disease or attribute on a particular date.

Period prevalence refers to prevalence measured over an interval of time. It is the proportion of
persons with a particular disease or attribute at any time during the interval.

Method for calculating prevalence of disease

All new∧ pre−existing cases during a given time period n

x 10
Population during the same time period
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Method for calculating prevalence of an attribute

Persons having a particular attribute during a given time period

x 10n
Population during the sametime period

The value of 10n is usually 1 or 100 for common attributes. The value of 10n might be 1,000,
100,000, or even 1,000,000 for rare attributes and for most diseases.

NAME: I.D.

BIOL 392 EPIDEMIOLOGY

Laboratory Exercise 2: Frequency measures used in Epidemiology

Questions:

1. Between 1971 and 1975, as part of the National Health and Nutrition Examination Survey
(NHANES), 7,381 persons
ages 40–77 years were enrolled in a follow-up study.1 At the time of enrollment, each
study participant was
classified as having or not having diabetes. During 1982–1984, enrollees were
documented either to have died or
were still alive. The results are summarized as follows.
Original Enrollment Dead at Follow-Up
(1971–1975) (1982–1984)
Diabetic men 189 100
Nondiabetic men 3,151 811
Diabetic women 218 72
Nondiabetic women 3,823 511
Of the men enrolled in the NHANES follow-up study, 3,151 were non-diabetic and 189 were
diabetic. Calculate the ratio of non-diabetic to diabetic men.

2. A city of 4,000,000 persons has 500 clinics. Calculate the ratio of clinics per person, per
every 100 persons and every 10,000 persons.

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3. Delaware’s infant mortality rate in 2001 was 10.7 per 1,000 live births.2 New Hampshire’s
infant mortality rate in 2001 was 3.8 per 1,000 live births. Calculate the ratio of the infant
mortality rate in Delaware to that in New Hampshire.

4. Calculate the proportion of men in the NHANES follow-up study who were diabetics.

5. Calculate the proportion of deaths among men.

6. In the study of diabetics, 100 of the 189 diabetic men died during the 13-year follow-up
period. Calculate the risk of death for these men.

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7. In an outbreak of gastroenteritis among attendees of a corporate picnic, 99 persons ate potato
salad, 30 of whom developed gastroenteritis. Calculate the risk of illness among persons who
ate potato salad.

8. The diabetes follow-up study included 218 diabetic women and 3,823 nondiabetic
women. By the end of the study, 72 of the diabetic women and 511 of the nondiabetic
women had died. The diabetic women were observed for a total of 1,862 person-years;
the nondiabetic women were observed for a total of 36,653 person-years. Calculate the
incidence rates of death for the diabetic and non-diabetic women.

9. In 2003, 44,232 new cases of acquired immunodeficiency syndrome (AIDS) were

reported in the United States.5 The estimated mid-year population of the U.S. in 2003
was approximately 290,809,777.6 Calculate the incidence rate of AIDS in 2003.

10. In a survey of 1,150 women who gave birth in Maine in 2000, a total of 468 reported
taking a multivitamin at least 4 times a week during the month before becoming
pregnant.7 Calculate the prevalence of frequent multivitamin use in this group.

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Figure 3.1 represents 10 new cases of illness over about 15 months in a population of 20 persons.
Each horizontal line represents one person. The down arrow indicates the date of onset of illness.
The solid line represents the duration of illness. The up arrow and the cross represent the date of
recovery and date of death, respectively.
Figure 3.1 New Cases of Illness from October 1, 2004 through September 30, 2005

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11. Calculate the incidence rate from October 1, 2004, to September 30, 2005, using the
midpoint population (population alive on April 1, 2005) as the denominator. Express the
rate per 100 population.

12. Calculate the point prevalence on April 1, 2005.

13. Calculate the period prevalence from October 1, 2004, to September 30, 2005.

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 Lab 3: Micro-Epidemiology and Index Case
Objectives

After completing this exercise, you should be able to:

1. Define index case and case definition

2. Determine the source of a simulated epidemic

Background
In every infectious disease, the disease-producing microorganism, the pathogen, must
come in contact with the host, the organism that harbors the pathogen. Comunicable
diseases can be spread either directly or indirectly from one host to another. Some
microorganisms cause disease only if the body is weakened or if a predisposing event
such as a wound allows them to enter the body. Such diseases are called
noncommunicable diseases i.e., they cannot be transmitted from one host to another. The
science that deals with when and where diseases occur and how they are transmitted in
the human population is called epidemiology. Endemic diseases such as pneumonia are
constantly present in the population. When many people in a given area acquire the
disease in a relatively short period of time, it is referred to as an epidemic disease. The
first reported patient in a disease outbreak is the index case. One of the first steps in
analysing a disease outbreak is to make a case definition, which should include the typical
symptoms of patients so you know who should be included.
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Diseases can be transmitted by direct contact between hosts. Droplet infection, when
microorganisms are carried on liquid drops from a cough or sneeze, is a method of direct
contact. Diseases can also be transmitted by contact with contaminated inanimate objects
or fomites. Drinking glasses, bedding and towels are examples of fomites that can be
contaminated with pathogens from faeces, sputum, or pus.

Some diseases are transmitted from one host to another by vectors. Vectors are insects
and other arthropods that carry pathogens. In mechanical transmission, insects carry a
pathogen on their feet and may transfer the pathogen to a person’s food. For example,
houseflies may transmit typhoid fever from the faeces of an infected person to food.
Transmission of a disease by an arthropod’s bite is called biological transmission. An
arthropod ingests a pathogen while biting an infected host. The pathogen can multiply or
mature in the arthropod and then be transferred to a healthy person in the arthropod’s
faeces or saliva.

The continual source of an infection is called the reservoir. Humans who harbour
pathogens but who do not exhibit any signs of disease are called carriers.

Materials
Petri plate containing Nutrient Agar

Nitrile or vinyl glove

Procedure
Case: Four friends Sally-Ann, Megan, Mike and Analice were all studying together in a
contaminated Biology laboratory for their Chemistry exam. Within two hours one of the
friends noticed a localized area on their arm was red, swollen and painful. After the
Chemistry exam the student exhibiting symptoms reported them to a physician at the
school’s Health Services Unit. The following Morning two other friends complained of
similar symptoms, however the fourth friend exhibited no symptoms. Keeping in mind
that they may have physically contacted each other while studying, carry out the
following procedure.

1. Obtain a petri plate containing Nutrient Agar from your Laboratory Technician.
2. Label your group number and date on the appropriate side of the petri dish.
3. Divide the Petri plate into 4 sections and label each section to represent the four
friends
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 4. Collect the gloves with the organisms found on each of the friends (4 gloves).
5. Using your index and middle finger transfer the microbes found on the palm of
each of the glove to the appropriate section on the petri dish.
6. Discard of your glove and the glove containing the microorganism from the
friends in a biohazard bag.

Results
Construct a table describing your observations

Questions
1. Who was the index case?
2. What would you consider the reservoir in this case study?
3. Diagram the path of the epidemic from the reservoir to the index case to all
“infected” classmates/ friends
4. Could you be an “infected” individual and not have a growth on your plate?
5. Do all people who contact an infect individual acquire the disease?
6. How can an epidemic stop without medical intervention?
7. Are any organisms other than the culture assigned for this experiment growing on
the plates?
8. What was the method of transmission for the disease in this experiment?
9. What was the size of the population in this case study?
10. What is the ratio of the infected population?

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 Lab 4: Immune Defense & Infectious Disease
Outline:

Expected Learning Outcomes

Introduction

Activity 1: Structures of the Lymphatic System

Activity 2: Transmitting Disease

Activity 3: Ebola Film

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Expected Learning Outcomes

At the end of this lab, you will be able to locate the major gross structures of the lymphatic system on
the human torso model; track the spread of disease and determine who was the first person to “get
sick”; and apply appropriate vocabulary and concepts to a real life infectious disease, ebola.

Figure 4. 1 Ebola Virus Approximately 60,000 X

Introduction

We are surrounded!! Surrounded by gazillions of things that might make us sick, including bacteria,
viruses, and parasites that we may get from other people. When an illness can be passed from person to
person, it is infectious. Diseases are transferred from person to person in a variety of ways—through the
air in droplets when one sneezes, or by direct bodily contact, or by touching a surface such as a
doorknob that was recently handled by a sick person.

Through millions of years, humans have evolved to combat pathogens, bacteria, viruses, or parasites
that make us sick. The myriad responses to infection are partly the job of the lymphatic system.
Different types of white blood cells recognize and phagocytize foreign invaders, produce antibodies, and
kill already infected body cells. Lymphocytes collect in the lymph nodes where they filter lymphatic fluid
and clone themselves in response to specific invaders. This is why lymph nodes become enlarged when
you are ill.

The study of the transmission of disease in populations is called epidemiology and it forms the basis for
public health strategies and interventions. An epidemiologist determines the origin of an outbreak of
infectious disease, for example, so that the source (such as a contaminated well or food) is identified
and the public educated about how to prevent infection.

Check Your Understanding: Answer the following questions based on your reading of the introduction.

1. What is the difference between infectious diseases and other types of diseases?

2. Give two examples of pathogens.

3. What are some ways white blood cells fight disease?

4. Why do lymph nodes enlarge when you are sick?

5. What do you suppose would be the job of an epidemiologist if there was a mysterious outbreak
of food poisoning in Santa Cruz county?

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Activity 1: Structures of the Lymphatic System

Use Fig. 4.2 and locate the following structures: (and Be able to label all the parts indicated in the figure)

Tonsils

Lymph Nodes

 Cervical
 Axillary
 Inguinal

Thymus Gland

Spleen

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 .

Figure 4.2 Lymphatic System

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Why do you suppose the tonsils are located in the back of the throat?

Why would a person with leukemia have a sense of abdominal fullness?

Activity 2: Epidemiology

Epidemiology is only one branch of the study of disease. Specifically, it is the study of the spread of
disease. Diseases such as the flu, the common cold, or intestinal infections are often transferred from
person to person by bodily contact, or by touching an object the person has touched. This exercise is
designed to demonstrate how an epidemiologist might track the spread of a communicable disease back
to the original source. We will use starch, which does not cause disease, as a model for examining how
microbes may be passed from person to person.

Procedure:

1. Each person will receive a dish that is identified with a number and filled with a clear liquid. This clear
liquid will represent your bodily fluids! All but one of the dishes will contain plain water. The exception
will be one containing a solution of starch. This solution represents the "disease" we will be tracking.
Write down your I.D. number in Table 4.1.

2. You will exchange fluids with another student in the room. Pour the liquid back and forth between
your dishes to thoroughly mix the liquids. This will simulate sexual contact and will represent the
pathway of infection for this disease. Write the ID number and name of the person with whom you
exchanged fluids.

3. Wait until everybody in the room has “done it” once before going on the next round. Repeat your
exchange of fluid with a new student. Keep track of your contacts' I.D. numbers and the order in which
you came in contact with them.

4. Once everyone has finished (please, no smoking) bring your dish to the front of the room for
“diagnosis.” We will use iodine to test for the presence of the "disease" (starch) by placing a few drops
in your dish. Contact with the "disease" will be indicated by a bluish-black precipitate formed in the
presence of the iodine.

5. If you were diagnosed with the disease, report the I.D. numbers of those you shook hands with. We
will use this information to determine the initial carrier of the disease.

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Table 4.1 Microorganisms and Disease Lab Data Sheet

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ID Numbers and Names of those you Your Name:
contact:
1 Your ID#
2
3
Contacts
ID Numbers and Names of those infected Round 1 Round 2

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Answer the following questions, based on results in Table 4.1.
1. How did you determine who was the initial carrier of the "disease"?
2. Was it possible to know precisely who the initial carrier was? Why or
why not?
3. Who were the possible initial carriers?
4. Describe two reasons why this lab is limited as a model for the spread
of disease.
Activity 3: Film: Ebola—The Plague Fighters
Questions:
What are the symptoms of Ebola?
What is the cause of Ebola? What is meant by a “reservoir” for the disease?
What is the reservoir of Ebola?
How is the Ebola virus transmitted? Why was it so important to isolate the
victims?
What are some current research questions about Ebola and what are scientists
doing to answer the questions?
Where has Ebola occurred so far?
What are some of the social, political, cultural, and economic issues
surrounding a disease such as Ebola?
What diseases in the United States have a stigma attached to them? What strategies do doctors
in the film use to overcome stigmas? What are public health workers doing in the U.S. to
overcome stigmas against disease?

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 LAB 5: Field Epidemiology: Investigation of an Unknown Disease
Objectives
During this activity, students will

· graph statistical data from an epidemic,

· calculate attack rates,
· analyze graphical data,
· design an experiment to investigate the source of a causative agent of an epidemic,
· compare the characteristics of known diseases with an unknown.

Background
Epidemiology is the study of diseases in human populations. Often diseases will “break out” in
certain areas and field epidemiologists are called in to identify the source of the outbreak and
institute measures to bring it under control. This is a very challenging job as such research is
often hampered in a number of ways. First, investigators usually arrive on the scene “after the
fact” and must reconstruct a picture of what has occurred from various and often inconsistent
sources such as personal testimony, records of outpatient visits or hospitalizations, and even
school absentee records. There are often a limited number of persons affected, which can make
it difficult to formulate statistically valid conclusions. In addition, some persons directly involved
with an outbreak may be reluctant to cooperate with investigators, especially if the results of
the study may have financial repercussions, e.g. the owner of a restaurant suspected of food
poisoning. Finally, local publicity of an outbreak can hamper a study as media coverage can
influence affected persons to form preconceived notions as to the source or cause of an
outbreak. Also, media demands on the investigators may require considerable time that could
be better spent on the field investigation itself.

In this activity, you will be given some of the details of a real investigation of an unexplained
outbreak. Using this information you will analyze the situation and form some conclusions as to
the cause of the epidemic and make suggestions as to how to remedy the situation.

The Situation
You are an Epidemic Intelligence Service (EIS) officer at the Centers for Disease Control (CDC),
Atlanta, Georgia. A request for epidemic aid comes to the CDC from the Michigan State Health
Department. There has been an outbreak of acute febrile (feverish) illness in the Oakland
County Health Department. You and two other EIS officers are assigned to investigate the
outbreak. You arrive at the health department early on Saturday, July 6, and assess the
situation.

The department building has two floors, one at ground level and a basement. It is situated on a
spacious “campus” of county service buildings and houses the administrative offices for the
Oakland County Health Department and several health clinics. During the first 3 weeks of June,
the ground adjacent to the building was graded and paved, which raised clouds of dust that

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enveloped the entire complex at times. Torrential rains occurred during the last week of June,
followed by a rapid rise in mean temperature from 15.2°C on June 29 to 27.4°C on June 30.
Beginning on the evening of Monday, July 1, the first employee of the health department came
down with an acute febrile illness. By Tuesday evening, over half of the employees had become
ill, and on Wednesday, additional cases were reported by some of the visitors to the building.
The building was closed on July 4, but then reopened on Friday the 5th.
By the time you arrive, 91 out of the 100 employees who worked in the building are currently ill
or have recovered. The director gives you the following list of their symptoms.

Defining a Case
Notice that in the list above, not all of the employee patients experienced the exact same
symptoms. One of your first jobs is to formally define exactly which persons represent a case of
the illness you are studying. If the disease is known, then a clinical definition will suffice.
However, in this example, the cause of the illness is unknown, so you will have to formulate a
working definition. An example of how this is often expressed is, “If a patient has 3 of these 5
symptoms, then they are classified as a case.”
· Which group of symptoms would you use to determine if a patient represented a “case?” Why
would you not want to include a symptom such as “sore throat” in your definition?

Making an Epidemic Curve

In order to determine how the cases are related by time, you will want to make a histogram
that plots the number of cases versus time. This will allow you to determine the magnitude of

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the outbreak, its possible mode of spread, and possibly the incubation period of the agent
responsible. In addition to the table of symptoms, the director of the health department
provides you with a list of the date that each employee patient first became ill. Use this data to
begin an epidemic curve for the employees. The bar for June 2 has been drawn in for you.

Determining Attack Rate

Attack rate is the proportion of the population that is at-risk for infection who actually develop
the illness over a period of time. You can calculate attack rate by using the following formula:

(Number of cases / Number of people potentially exposed) x 100%

· What is the attack rate for the employees at the time of your arrival on Saturday? (show work)

· What information must you have to determine an attack rate for the visitors? Why is it much
easier to determine the attack rate for the employees than for the visitors?

Continuing the Investigation

In taking a closer look at the employee and visitor cases you determine that these people vary
widely in age, ethnicity, occupation,and what they ate or drank just prior to their illness.
However, it does seem that the longer someone was in the building, the more likely they were
to come down with the illness. In addition, no cases were reported in county employees who
worked in the other buildings in the area.

What is the one thing that all cases appear to have in common?

· Formulate a hypothesis as to the source of the illness. Back it up with evidence that you have
collected.

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You work with your team in the building over the entire weekend and none of you begin to feel
any effects of the mysterious illness. You continue your investigation in the building as it
reopens on Monday, June 8. Late Tuesday evening, you and your two colleagues become ill.
During the second week of the outbreak additional employees and visitors report becoming ill.
You make the decision to close the building on Friday, June 12.
By July 17, 95 cases had occurred in the 100 employees exposed to the building. Interestingly,
none of their family members had become ill during this period.

· What does this information tell you about the transmission of the agent causing the outbreak?
Contacting the visitors to the health department proves a difficult task. Of the 170 visitors that
you were able to locate, 47 were considered to be cases.

· How would you go about identifying visitors to the health center?

· Calculate the attack rate for visitors to the health department. (show work)

· Why do you suppose that the attack rate is considerably lower for visitors than it is for
employees?

You compile all the data available on July 18 which is expressed in the table below. Add the new
information to the epidemic curve that you began above. Place bars for the visitors on top of
those for the employees so that it shows the total number of new cases for each day. Color the
employee and visitor bars in two different colors that you indicate in the key. Your stacked bars
will look like this:

· Are the epidemic curves for the employees and visitors the same? Give a possible explanation
for this.
You now suspect that you are dealing with something in the building itself that is causing
people to become ill.

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· What evidence points to this suspicion?
Incubation Period and Source of the Disease
Looking back at your completed epidemic curve, you try to estimate the incubation period for
the mysterious disease.
· About how long does it take someone to come down with symptoms after being exposed?

· Based upon this information alone, which would you suspect as the culprit?

· However, based on other evidence you have gathered, you choose to rule these out. Explain
why.

Taking another look at your graph, you realize that on some days, people in the building were
apparently not affected, but on others, they were. Noting that the air conditioning system was
turned off on the July 4 holiday and during the weekends, you begin to suspect that somehow it
may be linked to the illness. You investigate the air conditioning system to see if it may be
faulty.

The system consists of two air circulation systems that were separate, but had ducts close to
one another. One system cooled air returning from the building and some fresh air from an
intake on the roof. This air was then sent through ductwork to the offices in the building. The
second system contained a condenser unit in the basement that was cooled by water sprayed
over the condenser coils. Air was pumped over this system from the basement and vented on
the roof about 2 meters from the fresh air intake of the other system. The system is illustrated
below.

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Suspecting that somehow air from the condensing system was contaminating the adjacent air
supply duct you set off some smoke bombs in the condensing system ductwork.

· If your suspicions are correct, where would you expect the smoke to go?

· What types of samples would you want to take to try to identify the organism responsible for
the outbreak?

· Suppose you had some laboratory animals, such as guinea pigs, available for testing the air
conditioning system. Describe an experiment that you could perform to determine if the air
conditioning system in the health department building is really responsible. Be sure to include
replication and controls in your design.

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