384 CHAPTER10

ANsWERs— REVIEW EXERC∶ sE

An Outbreak of Enteritis IDuring a PⅡ gri了 nage to Mecca

Question1。 What information do you nced to decidc if this is an epidemic冫

Answer1.
・Is the number of cases rnore than the number expectedP
・Therefore,we nced to know background ratc。

Question2。 Is this an epidemkP

Answcr2。 Yes。 An cpideΠ lic can be dcsned as the occurrence of rnore cases
in a pIacc and tirnc than expectcd in the population being studied。 C)f thc
1101mcmbcrs without signs and symptoms of gastrocntcritis prior to thc
pⅡ griInagc,64(58%)devClopedsuch signs and symptoms during this trip。
This is clearly above thc expected or background rate of gastroenteritis in most
populations。 Gastroentcritis prevalcncc rates fron1recent surveys arc
approxiⅡ nately5°/。 and arc consistent with this population(2/112had such
slgns and symptoms at the timc of the pilgrimage)。
one could survey other grouPs of pⅡ griFns originating from the same
country to detcr∏ 1inc their rates of diarrhcal illness if the existencc of an
outbreak was uncertain。 Practically speaking,however,an attack rate of58°/。
Ⅱ
s an epideΠ lic untⅡ provcn othemisc。
he term“ outbrcak” and“ epidcΠ lic” are used interchangeably by most
1冂

epidemiologists.1□ hc term“ outbrcak” is sometimes prefOrred,particularly

when talhng to the prc$or pubk,because k沁 not as frightcning as
“epidcⅡ 1ic。 ”・ “
rhe ter∏⒒ cluster” may be dcsned as the occurrence of a group of
cases1n a circumscribcd placc and tiⅡue。 In a cluster,the numbcr of cases rnay
or rnay not be greatcr than expectcd。

Question3。 Dcvclop a prchminary case definiton。

Answcr3。 PoⅡ nts to cons1der:
・As a gcneraI rulc,during thc initial phasc of an invcstigation,the case
dc丘 nition should be broad。
・∶Γhe casc dcfinition should includc four componcnts:tiェ nc,place,person,
and diagnosis(or signs,symptoms).Depending on the frequency of the
mpt° ms。 bserved and the probable etiologic agcnt,a more precisc casc
溪
|efinition can be dcvcloped later。

Case dcε n1oon:

CJj″ 氵
c'J: acute onset of abdominal cramps and/or diarrhca
onset aRcr noon on Oα obcr31and beforc Novcmber2
T″ ″纟:
。 P切 ‘〃P纟 rs° ″: member of d1e Kuwaiti medical mission en routc to Mecca
№ 莎
纟:Thc Kuwaiti investigators had already decided that lunch on Octobcr31
' was the responsible Fncal and dcfined an outbrcak-associatcd case of cnteritis as
a pcrson in the lKuwaiti Ⅱlission、 〃ho ate lunch at Arafat at2:00P。 M。 on
oct° ber31and subsequently dcvclopcd abdoⅡ 1inal pain and/or diarrhea prior
to November2,1979。
⒈k)、 vevcr,at this point in your consideration of thc Outbreak you have
not Ⅱmphcated the lunch,and it would probably be premature to lirnit your
case de丘 nioon to those who atc lunch。
 NOw Ⅱ、 Vour Tu口 η:EˇaIuat:"g Vour Understand∶ 385
"g

Quest10n4。 List the broad catcgories of diseases that rnust be considcred in the
differcntial diagnosis of an outbreak of gastrointestinal illncss。

Answer4。
Broad categorics:
Bactcrial
Viral
Parasitic
△oxlns
More speci伍 cally:

Diffcrcn吐 al diagnosis of acute foodborne enteric iⅡ ness

Baderia amd1acte了 iaI to× ∶ Vir"ses

"s
Bac″ ∫
us cereusⅡ Non″ a丨 k-"ke agents(i。 e.`27nr11viruses)
Campy丨 obacter虍 加nj Rotavirus+
Clostrk″ um b° tu″ num
Tox1ns
(initia|synnρ toms)
Heavy meta|s(especia"y cadrnium`Copper`
Clos1rjdjum per衍 ngensⅡ
tin`zinc)
Escherjch`a co″ ・
Mushrooms
5a∫ n,one″ a`non-tγ phoid
Fish and sheHfish(e.g。
5a∫ mone∫ fa tyρ hj `sconlbroid`ciguatera)
jge″ a lnsecticides
5j氵

5taρ h/fococcus aureus Parask6

、/氵
Cr/ptospord汕 m
`,`focho∫
V氵 brjo cho`erae o1
erae nonˉ o1 Entamoeba hoto`ytjca
V`br氵 o ρarahemo`/t`cus G泅 rdja Jamb`ja
Yersjn泅 enteroco∫ jtjca

Ⅱnltlse agents arc most∞ mpaoble而 由 曲c fo11owing charaα crisocs of this outbrcak:

・l° wer CIs廴 s and symptoms

”
・no fever
・appreciabIe pr° portion seckng:nedk刁 l advicc
・no menoon of non-enterk(dematol° gic,ncurolo莎 c)manifestatons
Ho、vcvcr,you have not yet reached thc point in your invcstigaoon to considcr thc most likcly ctiologic
poss:bⅡ ioes for thc illness。

Qucst0n5。 what clinkal and emdem。 lo西 c informat0nm圯 ht bC hdpfuhn

detcrmining the ctiologic agent(s)P

Answer5。
Incubation period
symptoⅡl compleX
Duraoon of symptoms
seveo〃 of symptoms
seasonaⅡ 〃
Geographic locaoon
Biologic plauoibⅡ hy of pathogens

Quest0n6。 ⒒ e Kuw缸 ti invest圯 ators由 strIbuted a quesoohn茹 re to the

persons l〃 ho ate the impⅡ cated lunch。 Whatinformaoon would you sohcit on
this qucstionnaireP
 386 CHAPTER1o

Answer6。
・Identif、
・Demographics(age,scx,racc)
`ing information
・(0hnical infornlation
-Symptoms
-Datc and time of onsct of symptoms
-Du∏Ⅱion of symptoms
-Medical intcrvcntion,if required
・InforIuation on possible causes
hng bods coⅡ umcd,涮 u山 ng徊 0ums
二 :I:J贳 饣 t里 湍 :Jf戛
a“

-Other factors that may modify risk of diarrhea(c。 g。 ,antacids,

antibiotics)

Ques。 on7。 caIculate the attack rate for those who ate lunch and those who
did not。 、Vhat
do vou concludeP

Answcr7。
1121η cmbers of thc Ⅱ
ηission
-15mcmbers who didn’ t eat lunch
- 2membcrs sick bcfore pⅡ gHmagc
9jˉ 夕r/氵 s泛 oFJ召 v纟 Jop″ ″召ss
`gJ〃
! 64becamc iⅡ among those η
〃ho ate lunch
’
0b召 c'彬 纟 ″ J'妫 o〃 gr” os纟 ″ ” oJ耐 ″ r召 切 ″ ‘勿
'莎
Attack rate for those who atc1unch:64iⅡ /95at risk=67° /。
Attack rate for those not eating Iunch:o iⅡ /15at risk=o%
Conclusion:Lunch is strongly associated with discasc。

Question8。 using appropHatc time periods,draw an epidemic curve。

Answcr8。
Points for consideration about cpi curvcs:

1. The epi curve is a basic tool of cpideⅡ 1iologists to

a。 estabhsh existence of epideΠ lic vs。 cnde∏ 】

ic iⅡ ness
b, dchneatc ti:ue course and Ⅱ uagnitude of an epiden1ic
c。 dcvelop inferenccs about transⅡ ηission(e。 g” con1Iη on sourcc,person
to pcrson,inter1η ittent exposurc)。 Note that changing thc intcrval on
the‘ -axis can significantly alter the shape of an epi curve。
prcdict future coursc of an cpideΠ 1ic:whcn it wiⅡ cnd,that a second
d。

wave is underway,that sccondary cases are occurring,etc。

2. With con1Ⅱ ηon sourcc Outbrcaks,the width of the curve is dctcrⅡ nincd by
thc incubati° n pcriod,varying doscs,and host susceptibⅡ ity。
3. C)ftcn a few cases don’ t fit into thc body of an epi curvc。 such exceptions
may bc quitc important-ˉ as index cascs or other spccial situations。
4・ A″ 饧°厂汤″勿3:whcn the incubaton pcrod k known,由 e ma妊 mum
tirne pcriod on thc‘ -axis should not usually cxcced1/4to1/3of thc
Incubat10n pcrIod。

summary cf the tcmporal distribution(see Figurc10。 3)。

 NOW It`γ 0ur Turm:EvaIuatimg Vour lJndefsta"di"g 387

Ⅲ
31 N~h1
-・ Hour of oⅡ sgt

+ID+includcd for rcfcrcncc Only.

∏ GURE10.3 防 碰 -“ so‘ f″ 纟d臼 “ s oF召 〃 歹

O″ j莎 js3γ
”o“ /oFo“ 引 o厂 jJ切 6s,Κ “″
'j″
Mjsso″ ,A旧 fsJr,s'〃 d氵 A″ 3妇 ,OcJo3召 /3】 -Nov纟 8莎
叨 1,】 979

a。 C)11scts of Cases occurred over a pcriod of31hours cxtcnding from

5P。 M。 on October31to11P。 M。 on NoVember1。
b。 Onscts of53(82.8%’ )of the cascs occurred throughout the10ˉ hour
i:、 on OCtober31through7A。 M。 on November1。
terval from10P。 M。

The peak(12cascs)occurred at3A。M。 on November1。

The median hour of onset=⒊ 30A。 M。 Novcmbcr1(actual middlc

E・
d。

rank=32.5which falls bemeen the3and4A。 M。 measuremcnt

intcrvals)。
e。 It is hkely that thc way the questionnairc was designcd forced thc
intervicwees to give a roundcd tiFnc for onset of symptoms。

Question9。 Are therc any Cascs for Whidl the timcs of onset scem
inconsistentP How∏ 1ight thcy bc explainedP

Answer9。

1,Thc two cases(#31and77)with onscts at5P。 M。 on Octobcr31

a。 IⅡ nesscs unrclated to the outbrcakP
b。 Earlier cxposures to food ite△ 1sp CooksP
c。 short incubation periods冫 Largc doscsP Enhanced susceptib⒒ ityP
d。 Times of onsct incorrcCtP

2.Thc two cases(#75and95)occurring late on Novcmber1

a。 Illncsscs unrelatcd to the outbreak冫
b。 Foods caten at latcr tirncP
c。 secondary casesP
 388 CHAPTER1o

d。 Timcs of onset incorrcα P

e。 Long incubation pcriods冫 SmaⅡ dosesP Enhanced rcsistanceP

QuCstion1o.Modify the graph you havc drawn(QuCs。 on8)to illustrate the

distribution of incubation periods。

Answer10。
Since aⅡ Ⅱueal participants werc served at2:00P。 λ ⒋ the distribuoon of onsets
and incubation pcriods is the same.Thcrcforc,to iⅡ ustratc the distribution of
incubation pcriods,you need only to show a second label for the,c-',‘ 氵 s,as in
Figure10.4。

囤 〓1¨ ・

%J刂
N-ber1
:ncub:¤ I1ioo
peood

°ID#indudcd for refcrcncc Only。

Π GURE10.4 oBJJb″ -'sso‘ f'勿 d臼 sε s oF纟 ″招″rjs8γ ”o〃 r ofo,9s引 of`JJ″ 纟ss'″ d
'泛
加 刭 3″ 沁 Ft p″ 0站 Κ 〃伪叼订jM泌 so〃 ,^″ ,s'钌 dj^″
″ 矽 D拓 ,0‘ ro8″ 3】 ~Nov纟 ″ 3e/】 ,】 979

Question11。 Dctcrmine or calculatc thc minimum,maximum,mean,median,

modc,range,and standard deviation of the incubation pcriods。

Answer11。
Mi“ mum=3hours
Ma妊 mum=33hours
Mean=14hours
Median=13.5hours(middlC rank=64+1)/2=32.5,which falls bctween
thc intewals for13and14hours)
Mode=13hours
Range=ma妊 mum-minimum=30hours
Standard dev1at1on=5hours ~'
 NOw"′ s Vour Turn:Eˇ aluating Υour Understa"ding 389

Nor召 :The range in which roughly95° /。 of the observations fall=页 ± 1.96

(rounded to2)standard deviations=4to24hours。

Comment

∶ ∶∶ :∶ II∶ 甘
丨 i彳

’
,

拭群谳
路鞋噬
perods,whⅡ e Ⅱhcsses
羟 抒
爿擗骂 扌
抽恒Ⅰ
with predominately lowcr GI signs and symptoms,such
`珏
as diarrhea,havc longcr incubation pcriods。

Question12a。 Calculate the frequency of each dinkal symptom among the

cases。

Answer12a。
The distribut∶ on of signs and symptorrls arc givcn in%blc10.28。 E)iarrhca
ocCurred among aⅡ but two ofthc cascs,、 vith78.1°/。 experiencing both
冫
diarrhea and abdon1inal pain。 Blood in the stool⒔ as rCported by8(12.59乞 )

of the cascs。 SymPtoms of讧 pper GI distross occurrcd among4(6.3%)of the

cases(2pcrsons experienced nausea whⅡ C t、 vo othCrs rcported voⅡ 1iting)。 No
tcmpcrature elevations、〃ere rccorded.

TABLE10.28 Frcqucncy distribution of signs and symPtoms among outbrcak-associatcd

cascs of cntcritis,Kuwaiti Mission,Arafat,saudi Arabia,October3⒈ Novcmber1,1979
01=6⑴

5氵 gn or Symρ tom Number of Cases

Diarrhea 62 96,9
Abdomina|pain 52 81.3
pain) (50) (78.1)
(【 Diarrhea+abdonlina丨
B|ood in stoo| 8 12.5
(7.8)
(Diarrhea+b|ood in stoo|) (5)
(4.7)
(Diard1ea+abdornina丨 pain+b丨 ood in stool) (3)
3.1
Nausea 2
Vomiting 2 3.1

Fever 0 0

on12b。 How does thc inforⅡ nation on the symptonls and inc讧 bation
。Ques。
period hd0you t。 naⅡ ow the dⅡ ferenthl dagnos“ p(γbu may refcr to the
attaChed Compendium in Appcndix】 D,which describcs a number of acute
foodbornc gastrointesonal diseases。 )

Answcr12b。
ls,
The c⒒ nical findings,including an apparcnt absencc of rnalaise,rnyalgias,chⅡ
and fcvcr,are tnore consistcnt with an intoxication rcsulting fron△ the prcscnce
of toxin in thc lowcr(3I tract than、 〃ith an invasive infectious agcnt。 The
390 CHAPTER10

recovcry of aⅡ cases、 〃ithin24hours is also consistent、 vith such an

intoxication。 Thc absence of der1η atologic and neurologic signs and symptor11s
in conjunction with the incubation pcriod(thc Iuedian、 vas13.5hours and the
mean was14hours)would lesscn thc likehhood of heavy n1etals、 organic and
inorganic chen1icals,and toxins produccd by fish,shcllfish,and mushroorns。
⒒ e incubation period and chnical features help narrox17thc list to thc
following:CJosrrjd砌 ″ pε /F/f″ g纟 ″s,B'σ 〃助s‘ ″召〃s,、 厂 。p'r'” 召P99oJyr庀 ‘ fs,
'8冖producing E。 ‘
and,lqss likcly,V氵 3/Jo‘ /9° J召 /四 召non-(D1,and cnterotoxin o″ 。

Qucst0n13a.Using the food consumpton histories in Table10.22,complete

item7of thc‘ ‘
Investigation of a Foodborne Outbreak” report forIu in
Appcndix E.

Answcr13a。

#Pers0冂 s1〃 h0^TE5ρ ecjF氵 ed fOod #V、 /ho D∫ D NOTE^T5pec`F氵 ed FOod

h/e″ Tota` ^ttack Rate ⒕妇〃 TOta∫ ^ttack Rate

RicMe“

665
230

322

987

386
156

065
66.7%

214

279
100.0%
71.6% 14.3%
65.8% 73,7%

You:nay analyze these data with2× 2tablcs:

lLL WELL T0TAL A‖ ¤Ck R¤ le

¤ b ¤ +b AR彳 =¤ /¤ +b RR= AR1/AR2
εXposed?
诧 C d C+d AR2=C/c+d
¤+C b+d T=¤ +b+c+d

VVELL T0tAL A‖ ¤Ck R¤ |e

R
R

AIe Ves 62 31 93 62/p3= bb,7%

__

66,7/100
RiCe No
〓

2 0 2 2/2 =100。 0% 0.67

64 31

VVELL TOTAL A‖ ¤Ck R¤ le

Ale Υes 63 25 88 63`88 = 71‘ 6% RR = 72,b/14,3
Me¤ t No 6 1/7 =14.3%
7 = 5,0
64 31

VVELL T0TAL A付¤Ck R¤ |e

e
R
R

A丨
Yes 50 26 76 50/76=bs。 8%
_~

Tom¤ Io 65,8/73.7
No 14 5 10/19=73.7%
〓

s¤ uce 19 o∶ 89
64 31
 NoW It's Vour丁 ur":Evaluat:"g Vour lJnderstand∶ mg 391

Question13b。 Do thesc calculations hdp you to determine whkh food(s)

served at the lunch Ⅱ
uay have been responsible for the outbreakP

Answer13b。
Attack ratcs werc high for thosc who ate Hce,meat,and tO△ 1ato sauce。
Howevcr,rneat is the likely culprit becausc it was thc Only food associated with
a high attack ratc among thosc who ate it,but a low attack ratc among those
who did not。 Almost all(63炻 4)who ate meat also atc thc Othcr itcms,which
probably accounts for the high attack rates for thosc itcrns,too。
one of thc cases did not adⅡ lit to eating rncat and could be explaincd in
any numbcr of ways:
・Unrdatcd Ⅱlncss
・Cross-contan1ination,e。 g” conlⅡ uon scrver,spoon,dish,countcr,etc。 ,or
fron1meat to rice
。】
Reporting error(c。 g” forgot or purposely denied eating:η eat)
・冂
Γranscription crror(e.g” rnisrecordcd response)

No莎 纟:Epiden1iologic evidcnce shows an association betwccn exposurc and

subscqucnt disease but does not prove causal relationship。

Qucs。 on14。 Oudine further invcstigations which should be pursucd.List

one or:nore factors that oould have led to the contan1ination of thc
irnpⅡ cated food。

Answer14。
A。 DetaⅡ cd rcview of ingrcdients,preparation,and storagc of
incrhninated food。 For bacterial food poisoning need:

1) initial combination(point of origin vs。 point of consumption)

2)improper time-temperature relatonshps with respect to
preparation,cooking,serving,and storage

B。 Spccinc things about which onc:night inquirc:

1)origin of the mcat-some sourc0s may be at higher Fisk than

others。 Animal meats are often contaminated at time of slaughter。
t11is aspect is usually quite difficult to control。 .
2) storage of rneat to ome of cooking(should be kept frozcn or
’
refrigcrated)。 rhis usuaⅡ y doesn’ t pose proble1ns and sinCc luost
meat is99o莎 eaten raw,subsequent cooking would considerably
lessen the risk of disease。
3) Cooking procedures-ˉ oRcn difficuk to oontrol both in pubhc/
private sectors。 Tempcratures a汪 ained and duration of optimum
cooking temperatures poody monitored。 FaⅡ ure to reach adequate
cooking temperatures associated with diseases other than C。
perf/imgc″s for the most part。
4)Cross-contaminatonˉ —a factor difficult to control盂 nce hhes,
counter space,cutting boards,and pots or pans are oRen used for
both raw foods and cooked foods without interi:n cleansing。
5) InadCquate refrigcration of cooked foods-ˉ conⅡ non in C。
pε rF/iⅡ ge彳 s outbreaks。 Cooked foods essentially allowed to
incubate for several hours during coo⒒ ng process。 Not easy to
correct as tnay involve expenditures for addioonal refrigeraoon
apphances and use of shallow pans。 /
 `J

‘ 、
、、

h
氵 、

392 CHAPTER10

6) Inadequate reheating of cooked foods-ˉ as with3)。

7) Improper holding temperatures whⅡ e servingˉ ˉHcre again,
difⅡ cuIt to contro1but coⅡ Ⅱ nonly associated with discase
outbreaks including C。 pε /F/j″ g纟 ″
s。 The food was essentially held

at temperatures that per∏littcd the growth of contaΠ linating

organisms rathcr than at140°F or abovc which、 vould have
prevcnted their Ⅱ
nultip⒈ cation。

Qucstion15.In the context of this outbreak,、 〃hat control:neasurcs would you

reconlⅡ mcnd冫

Answer15。
1. After collecting appropriate spcciFnens for laboratory analysis,destroy
remaining f° ods to prcvcnt their consumption。 D
2. Prevent recurrence of siFnⅡ ar evcnt in thc future。

a。 Educate food hand℃ rs in pr。 per tcchniqucs,stressing importancc of

tirne一 temperaturc rclationships。
b.Acquire necessary equipment for prooerly cooking,cooling,∝ n沁 ng,
~ and storing foods。
c。 Whcn apphcablc,chn1inatc sources of contan1inatcd food。

3.Basic principles in prevention of C。 p纟 /frj,9g纟 彳

s.

a. uinhnum internal terrlp。 rature of165° R

Cook aⅡ foods to Ⅱ
b。 serve imⅡlediatcly or hold at)140° R
c。 Any leftovers should be discarded or iΠ Ⅱnediatoly chⅡ led and held at
(40° F using shaⅡ oⅥ
`pans。
d。 AⅡ lcftovers should bc rehcatcd and held at tempcratures givcn abovc
for cooked foods。

Quest0n16。 Was itimportant to work up this outbrcakP

Answer16。
Reasons why k was important:
1.刁 R3dentify factors assooated with its occuⅡ enCc in order to insotutc the
necessary measurcs to prcvcnt futurc recurrenccs。
2. 1o provide rcassurance that a dchberate act of poisoning was not
involved。
3. 1o demonstrate that Pubhc health of丘 cials can react prompdy to a
problem and dentify causativc factors util汔 ing epidemk⒒ o臣 c methods.