Exercise on Analytic Epidemiology designs

Review the following abstract and answer the following questions in brief
paragraphs. Please keep you answers concise. For many of these questions
there are no ‘right’ or ‘wrong’ answers. Instead, it will be a matter of
interpretation.

Exercise 1

Part 1:

On the morning of November 1, 1979, during the pilgrimage to Mecca, the

epidemiologist assigned to the Kuwaiti medical mission experienced acute onset
of abdominal cramps and diarrhoea at the holy mosque before the walk around
the Kaaba. He subsequently learned that other members of the mission had
developed similar symptoms. When he returned that evening to Muna, he
initiated an investigation. Several ill members of the mission were interviewed by
the epidemiologist to better characterize the illness. On the basis of these
interviews a questionnaire was quickly prepared and interviews were conducted
with the 112 members of the Kuwaiti medical mission. A total of 66 cases of
illness were identified; 2 had onset in Kuwait prior to the beginning of the
pilgrimage and 64 had onset of symptoms beginning late in the afternoon on
October 31 following a communal lunch.

1. What hypotheses could be formulated as this stage?

2. What study design would you use to test these hypotheses?

3. Why is this design appropriate?

4. What is the appropriate measure of association to use in the analysis of

this study? Draw up a 2 x 2 table showing how the formula is calculated.

1
Part 2:

4. Using the table provide calculate the appropriate measures of association for
food items consumed at the lunch and interpret.

# persons who ATE specified food # persons who DID NOT EAT
specified food
ill total Attack RR ill total Attack RR
Rate Rate
Rice 62 93 2 2
Meat 63 88 1 7
Tomato sauce 50 76 14 19

Exercise 2

Part 1:

On October 31, 2005, the provincial department of health was notified by two
physicians in Town X that over 50 cases of acute pneumonia had occurred
among local residents. Most cases had occurred within a 3-week interval from
mid- to late October. All cases had occurred in adults. Clinical histories from
several patients suggested that the illness may have been Legionnaires’ disease,
caused by infection with the bacterium Legionella pneumophila. Review of charts
of pneumonia patients at Hospital A during October revealed that many patients
had fever, weakness, lethargy, and mental confusion. Some patients had a dry
cough, and several reported having watery diarrhea. Chest X-rays showed
patchy infiltrates indicative of pneumonia. Most patients were residents of Town
X and surrounding areas. Serologic testing of several patients during the initial
phase of illness had been negative for Legionella antibody.

Cases of Legionnaires ‘disease occur sporadically [individually] and in outbreaks.

The reservoir of the causative organism is primarily aqueous, such as hot water
systems, air-conditioning cooling towers, and evaporator condensers. The mode
of transmission is airborne via aerosol-producing devices. At this point in the
investigation, the leading hypothesis was outdoor exposure to cooling towers,
primarily because previous studies had demonstrated the role of cooling towers
as sources of the Legionella pneumophila in other outbreaks, and there were
several such towers in the town. However, rather than jumping to conclusions
based on this information alone, investigators began to compile a list of retail
stores and other establishments which were frequently mentioned by some of the
case patients who had been interviewed. The investigators also noted the
unusual preponderance of female cases.

1. What hypotheses could be formulated as this stage?

2. What study design would you use to test these hypotheses?

2
 3. Why is this design appropriate?

4. What is the appropriate measure of association to use in the analysis of

this study? Draw up a 2 x 2 table showing how the formula is calculated.

Part 2:

5. Using the table provide calculate the appropriate measures of association for
the various exposures and interpret.
Cases Controls
Exp Total % Exp Total % OR
Outdoor exposure to stores near paper
mill cooling towers

Restaurant A 2 26 5 52
Butcher Store A 12 27 10 54
Retail store A 10 28 15 52

Exposures to stores frequently reported

by case patients

Grocery store A 25 27 28 54
Grocery store A 19 28 23 54
Retail store B 22 28 30 54