Epidemic Investigation 2 Dr.

Josephine Carnate

IDK2014. RCL.

Before we go through this exercise we need to understand and know by heart the 5 steps in Epidemic investigation. 1. 2. 3. 4. 5. Verify the diagnosis Confirm the existence of an epidemic Characterize the epidemic as to person-place-time Identify the etiologic agent and mode of transmission Identify the population at risk and institute control measures

*if you want to understand every step, just go through the previous lecture we had. EXERCISE: EPIDEMIC INVESTIGATION Case: On the evening of April 28, a total of 100 people went to ER department of 3 local hospitals in Greenport, a suburban neighborhood. All of the patients complained of headache, fever, nausea, vomiting, and diarrhea. Stool samples were collected from all 100 patients: stools from 90 patients were positive for bacteria. They were all (90) diagnosed as cases of gastroenteritis. Questions: Step 1: Determine the disease. 1. What was the disease being considered? Gastroenteritis 2. What was the case definition? Stool sample positive from bacteria and positive from the sign and symptoms, headache, fever, nausea, vomiting and diarrhea *at this point in time we have already completed the first step, and the sign is when the reported cases is equal to true cases. In this case even if we have 100 initial cases that were supposed to be Gastroenteritis, we actually narrowed it down to 90 as true cases of gastroenteritis. Step 2: Confirm the existence of epidemic Check if these 90 cases of gastroenteritis represent an outbreak. Was there an outbreak of gastroenteritis? We dont know yet, because we need to compare it with the usual occurrence of gastroenteritis in that particular population, in particular place and time. Gastroenteritis outbreak like this usually caused by the consumption of contaminated or poisoned meal/food contamination may be caused by pathogenic viruses or bacteria. However, acute outbreaks are more often produced by toxins from Staphylococcus spp., Clostridium perfringes, Salmonella spp. and Vibrio cholarea. *we are now looking into possible causes of gastroenteritis outbreak.

The local health department was notified of the potential food-borne outbreak of outbreak of gastroenteritis. An epidemic team was sent to the area to gather data on the distribution of the disease by person- place time. The team came up with the following data (Table 1, Table 2 and Table 3) *the local health department is doing 3rd step of Epidemic Investigation, which is characterizing the epidemic as to place, time, and person. Sa last lecture na dicsuss na ung kachurvahan reviewhin na lang natin . Step 3: Characterize the epidemic as to person- place- time 3.1 Characterizing epidemic as to time: Tools: epidemic curve (this can also help us in determining the type of epidemic we have) 3 Types of Epidemic curve. 1. Explosive point source 2. Bell- shaped- propagated 3. Plateau- mixed?? *we can also determine the probable time of exposure 3.2 Characterizing according to person: Tools: attack rate; specifically age specific and gender specific attack rate Attack Rate= #of new cases / # of pop. At risk 3.3. Characterizing according to place Tools: place specific attack rate. Then look for spot map where cases are distributed Going back to the case this is the data that the health chenes (editor: anong chenes to baks???) gathered. Table 1. Distribution of cases by time of onset of symptoms Time of onset symptoms April 28 8pm 9 10 11 12am April 29 1 Total of Number of cases 2 18 30 24 12 4 90

Table 2. Distribution of cases by age and gender Age 0-5 6-10 11 Total Female 1 38 10 49 Males 1 38 2 41 Total 2 76 12 90

Question: 4. Draw the epidemic curve. What is the shape of the curve? What type of outbreak does the shape of the curve suggest?

30 28 26 24 22 20 18 16 14 12 10 8 6 4 2 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2

April 27

April 28

April29

Time of onset of symptoms

*plot the detail on the 1st table using the epidemic curve. Kung nasa inyo pa ung hand-out naman ang swerte niyo pero kung wala plot na lang natin. First draw the epidemic curve, on your x axis is the time of onset of symptoms,and on y axis is the number of cases. hindi ako marunong gumawa ng table hindi ako karpintero. (Editor: ewan ko sayo!! Hahaha!) Answer: Explosive epidemic curve, sudden increase and sudden decrease, suggestive of point source epidemic (remember lecture 1?)

5. When was the probable time of exposure? The usual incubation period of gastroenteritis is 1236 hrs, with mean of 24 hrs. Determine the most probable time of exposure using mean incubation period method and minimun and maximum incubation period.

30 28 26 24 22 20 18 16 14 12 10 8 6 4 2 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2

April 27

April 28

April29

Time of onset of symptoms

Mean incubation period method : Mean incubation period of gastroenteritis is 24 hrs 1. Identify the peak of the epidemic (median) *peak is the median case. In this case we have 90. What is the median case? 45. Then locate when was the 45th cases diagnose, which is April 28, 10 pm. 2. Count back in time one (mean) incubation period. *in this case 24. Because we are using mean incubation period. Probable time of exposure wa s 10 pm of April 27. Think of the thing happen on this time. Minimum-maximum incubation period method: The usual incubation period of gastroenteritis is 12-36 hrs 1. Count back from 1st case the minimum incubation period.

*The first case happen at 8 pm of April. Then count back 12 hrs since this is the minimum incubation period. 2. Count back from last case the maximum incubation period *last case was from 1pm of April 28. Then count back 36 hrs. Probable period of exposure is anytime from 1pm of April 27 to 8 pm of April 28. Look into what they were eating, where they were eating. Hypothesis: The people could gotten have expose starting from april 27 1pm to april 28 8pm (this is using your max. and min. incubation period method) or its from 10 pm of April 27. 6. Which population was most affected? (describe as to age and gender) Table 2. Distribution of cases by age and gender Age 0 5 610 11 Total Females 1 38 10 49 Males 1 38 2 41 Total 2 76 12 90

*characterizing according to person. Using table two we can not compute for the attack rates since we dont have the total population at risk, what we have in table 2 is the total population who got ill. But with this table we can see the most affected population according to age which is 6- 10 yrs old and according to gender which is female Hypothesis: Being gastroenteritis female and being 6-10 yrs. old might put you at more risk in having

7. In what other way(s) can the affected population be described? Table 3. Distribution of the population by places where they ate Place Local hotel Local Restaurant Lions Club Lunch School Cafeteria # ATE at the place # with symptoms ATTACK RATE 207 246 475 289 61 25 68 67 29.47 10.16 14.32 23.18

*we want to know where they were eating. In this table we can already compute the attack rate since we have the population at risk which is the number of people who ate at the place and new case as the number with symptoms *which place has the highest attack rate? Local hotel and school cafeteria, we need to look into this places. *we can also look into other characteristic of the person who got ill like occupation, where they live etc. But essentially as long as you have age gender, place they ate and probable time of exposure, more likely you cover all of the cases. 8. What hypothesis were generated by findings of the descriptive epidemiology? The most probable time of exposure is on April 27 to April 28. And the population at risk female and 6-10 yrs. old are at risk. And the place were they are eating is local hotel and school cafeteria. Step 4: Identify the source of the etiologic agent We are to establish the relationship between exposure and outcome. In the sense we want to test our hypothesis. We are going to do analytic study, analytic study that we can use is retrospective cohort and case control study. We can not do cross sectional because we want to determine causation and in cross section we ca not do that, it is the weakest. We ca not also do RCT because is unethical. We can do prospective cohort study but we do not have the luxury of time . 1. The epidemic team conducted analytic study and investigated the places where the affected persons, their relatives and neighbors ate on April 27-28. The following were their findings

Table 3. Distribution of the population by places where they ate and development of symptoms Place #Ate at the place #with symptoms Attack Rate #DID NOT eat at the place 157 # with symptoms Attack Rate RELATIVE RISK

Local Hotel Local Restaurant Lions Club Lunch School Cafeteria

207

61

29.47

47

29.94

0.98

246

25

10.16

122

13

10.66

0.95

475

68

14.32

189

29

15.34

0.93

289

67

23.18

495

22

4.44

5.22

ATTACK RATE FORMULA Attack rate = # of new cases_____ # of population at risk RELATIVE RISK FORMULA Attack Rate among the exposed__ Attack Rate among the unexposed

2. What research design did the epidemic team use? Retrospective Cohort because we are comparing the exposures, those who ate the place and those who did not. In case control we are going to compare those who had gastroenteritis and those who did not. 3. Compute for the attack rate (per hundred) by place. Which places had the highest attack rates? Essentially we are computing the measure of association, relative risk. 4. Compute for the relative risk (compare attack rates for those who had ate and did not eat at particular place the contaminated food most likely served? if we are going to compute for the relative risk of developing gastroenteritis when the exposure is eating at local hotel we will need to do it per place. The exposure is eating or not eating at the local hotel. And compute for relative risk. For exposureof eating at local hotel you have to do the 2x2 table. And compute for relative risk.

PLACE: LOCAL HOTEL (2 x 2 table) With symptoms Ate Did not eat Total 61 (A) 47(C ) Without symptoms (B) (D) Total 207 157

RR=A/ A + B C/ C + D = 61/ 207 47/ 157 RR= 1 (-) association

0.98

RR (+) association >1 causative ,<1 preventive *Just look into the table guys. On the table the place that has the highest relative risk is the school and suggest that it is the place of cause of gastroenteritis. What place is the cause of gastroenteritis epidemic? SCHOOL CAFETERIA After the place of exposure was identified, the team searched for the food that was most likely contaminated. The team discovered the following: ATE the food item Food item # Burritos #with symptoms ATTACK RATE 10.14 9.63 46.67 7.91 54.55 10.29 DID NOT EAT the food item # # with ATTACK symptoms RATE 10.15 10.69 5.05 14.55 8.96 24.14 Relative Risk

276 28

266 27 131 14 297 15 213 31 279 25 203 49

0.99 0.90 9.24 0.54 6.09 0.43

Cheeseburger 218 21 Salad Baked potato Fruit cocktail Ice cream 105 49 139 11 88 48

175 18

Question: 5. What research design did th epidemic team use? COHORT 6. Compute for attack rates (per hundred) by foof eated. Which food had the highet attack rates? 7. Compute for the relative risk (compare attack rates for those who ate and did not eat a particular food). What was the food item implicated as sources of the outbreak? SALAD and FRUITCOCKTAIL (look at the table) Preventive: ice cream, baked PATATAS Not at all related: burritos BURRITOS With symptoms Ate Did not eat Total 28 27 Without symptoms Total 276 266

*with the table already compute food source that cause gastroenteritis are salad and fruit cocktail. Food that is preventive are baked potato and icream since value is less than 1. It was found out that Juan, a cook in the cafeteria, prepared the implicated food. Samples from the implicated food revealed they were contamionated with salmonella toxin. The stool of Juan was examined; it too yieled Salmonella. The following measure were undertaken 1.) All left over contaminated food were discarded; 2.) Juan was not allowed to work until he has received antibiotic treatment. Step5. . Identify the population at risk and implement control and preventive measures 8. Classify the prevention measures undertaken as to nature. 1. Control the source of the pathogen. *kill Juan (DIE JUAN! Hahaha) cure Juan; discard all the food. 2. Interrupt the transmission of the disease. *remove intermediate host 3. Control or modify the host response to exposure. *immunization, vaccination etc. In this particular case we just control the source of pathogen.

CASE-CONTROL- we are dealing with rare disease. Measure of association: odds ratio

*kung nakalimutan nyo na ung formula.:) COHORT- we are dealing with rare exposure. Measure of association: Relative risk

MUST REMEMBER!!!! FORMULA NG ATTACK RATE AND RELATIVE RISK TSKA PAG RR=1 OR RR 1.. OKAAAAY? LETS ALL KILL JUAN. JOKE! HIHIHI! ---------------------------------------------------END OF TRANSCRIPTION---------------------------------------------------