Assignment

Subject: Epidemiology

Name: Melissa Peart

Instructor: Dr. Tamu Davidson-Saddler
Group: Master of Public Health
October 26, 2009
1. In 1990, the population of Cambridge district was 40,518 and there were 200 deaths due to

pneumonia in this district. The population of Mocco district in 1990 was 24,009 and there
were 200 deaths due to pneumonia.
a. Calculate the mortality rate for all deaths due to pneumonia in Cambridge district.
Ans.: Annual mortality rate for all causes(per 1,000 population) = (Total no. of deaths from all
causes in 1 year/ No. of persons in the population at midyear) X 1000.
= (200/40,518) X 1000
= 4.936
b. Calculate the mortality rate for all deaths due to pneumonia in Mocco district.
Ans.: Annual mortality rate for all causes (per 1,000 population) = (Total no. of deaths from all
causes in 1 year/ No. of persons in the population at midyear) X 1000
= (200/24009) X 1000
= 8.330
c. How would you describe the mortality rate of Cambridge district compared to the
mortality rate in Mocco district?
Ans.: The mortality of Cambridge district when compared with the mortality rate in Mocco
district is less because it is 1.69 times higher in Mocco district than in Cambridge district.
2. Marley parish has a population of 500,000 males and 450,000 females. Approximately
70% of males and females are of childbearing age. During one year, there were 4000
pregnancies, 1500 live births, 40 deaths among those <28 days of age, 75 deaths among
those <90 days, 180 deaths among those <1 year and 50 maternal deaths.
a. Calculate the birth rate for Marley parish.
Ans.: b = B/N
Where: B is number of births, b is the birth rate and N is the total number of people
b = 1500/950,000
= 0.001579
Approximately 1579 births per 1,000,000

b. Calculate the infant mortality.

Ans.: Infant mortality rate: The number of children dying under a year of age
divided by the number of live births that year.
= 180/1500
= 0.12
Approximately 12 infant deaths in a 100 births.
c. Calculate the neonatal mortality rate
Ans.: Neo-natal mortality rate is the ratio of the number of deaths in the first 28
days of life to the number of live births occurring in the same population during
the same period of time.
= 40/1500
= 0.027
Approximately 27 deaths for every 1000 live births among newborns who were less than 28 days
old.
d. Calculate the proportion of infant deaths between 28-90 days.
Ans.: Proportionate mortality = (no. of infant deaths between 28-90 days/ total no. of deaths in
Marley parish in one year) X 100
= (115/345) X 100
= 0.3333 X100 = 33.33 %
e. What proportion of child bearing age women became pregnant that year
Ans.: Proportion of child bearing women who became pregnant = (no. of pregnancies/ no. of
females of child-bearing age) X 100
= (4000/ 315,000) X 100
= 1.27 %
3. Incidence and prevalence data have different applications in public health. Below is a list
of uses for data. Please indicate by choosing the appropriate option whether the use is for
incidence or prevalence data.
A. This is a use primarily for incidence data
B. This is a use primarily for prevalence data
C. This application could apply equally for both incidence and prevalence data
D. This is a use for neither incidence or prevalence data
__B___
For determining workload and planning the scope of facilities and
manpower needs
___A__
__C___

For estimating the frequency of exposure

To provide a direct estimate of the risk of developing a disease

4. Using information provided in Table 1 below, calculate the cumulative incidence of

coronary death (expressed as the average annual deaths per 1000 persons per year) in each
smoking group. Report rates to the nearest tenth. Also calculate the incidence density
(expressed as deaths per 1000 person-years) in each group.
Table
1. Risk
of
coronar

y death,
by
number
of
cigarett
es
smoked
per day,
for
1,416
employe
d
middleaged
men:
St.
Johns
Factory
Study,
22-year
followup.
Cigarettes No. at
per day
risk
0

645

1-14
15-24
25-60

197
387
187
1,4
16

Total

Personyears
12,75
7
3,794
7,074
3,244
26,86
9

No. of
coronary
deaths

Risk per 1000

persons per
year

Risk per 1000

person-years

84

130

33
73
42

168
189
225

9
10
13

232

712

39

Risk per 1000 persons per year = no. of deaths/ no. at risk
Risk per 1000 person-years = number of deaths/ person-years
5. A survey of respiratory disease was conducted with results shown in Table I below.
a. Calculate the prevalence of chronic bronchitis in each age group and in the total

group.
Table 1.
Prevale
nce of
chronic
bronchit
is, by
age, in

a
sample
of 1,581
employ
ed men:
Bird
Island
2007.
Age
Number
Frequency Prevalence (%)
(years) Surveyed
45-49
496
18
3.6
50-54
672
18
2.7
55-59
1215
18
1.5
Total
2383
54
78
c=
0.983, p
= 0.612
2

b. Although the frequency of chronic bronchitis was the same in each age group, the

prevalence varied. Describe what the strata-specific prevalence reveals. Why might
the crude prevalence (total cases divided by total population) be inappropriate for
describing this situation?
Ans.: Strata- specific prevalence has to do with the burden of disease on a particular group in a
population. In this case, the group being focused on were employed men of different age ranges
who had a particular respiratory disease. The study found that although the frequency of the
disease was similar for all the given age ranges, the population for each differed. It can be seen
that the prevalence for the disease was higher between men ages 45-49 as their population was
the smallest while the prevalence for the employed men between 50 54 was smaller and the
least amount of prevalence occurred between ages 55- 59.
As defined by the world health organisation, a crude prevalence rate is defined as the number of
specified risk factor occurrences (i.e. daily smokers) over a specified period of time (e.g. a year)
divided by the total population sampled.
Crude prevalence rates are usually expressed as per cent of population sampled and may be
calculated for males, females, persons or some other subset of the population.
This would be inappropriate in this situation as this was a survey of respiratory disease and not
the specified risk factors for a disease. It would also not give a true picture of what is happening
in the population because all the cases would be integrated and the specificity as to where the
occurrence of the disease occurred would not be clearly seen (a demarcation would not be
observed).
PART II PUBLIC HEALTH SURVEILLANCE
Background on Salmonella
Salmonellosis is a gastrointestinal illness caused by bacteria from the genus Salmonella. The
illness is characterized by the sudden onset of headache, abdominal pain, diarrhea (which may be
bloody), nausea, and sometimes vomiting. Fever is almost always present. The illness typically

lasts for 5-7 days and usually does not require treatment unless the patient becomes severely
dehydrated or the infection spreads from the intestines. In the immunocompromised host or an
overwhelming infection in a normal host, Salmonella may spread to the blood stream and other
body sites, and can cause death unless treated promptly with antibiotics.
Salmonella live in the intestinal tracts of humans and other animals, including mammals, birds,
and reptiles. Salmonella are usually transmitted to humans by eating foods contaminated with
animal feces. Implicated foods are typically those of animal origin, such as beef, poultry, milk,
or eggs, but all foods, including vegetables, may become contaminated. The incubation period
for salmonellosis is usually 12-36 hours, but can be as long as a week.
6. How is salmonellosis diagnosed? How does the method of diagnosis impact our

understanding of the occurrence of salmonellosis in the community (e.g., burden of

disease, trends over time, high-risk populations)?
Ans.: Salmonellosis can be confirmed by isolating the organisms from feces or, in cases of
disseminated disease, from the blood. Salmonella will grow on a wide variety of selective and
non-selective media including blood, MacConkey, eosin-methylene blue, bismuth sulfite,
Salmonella-Shigella, and brilliant green agars. Enrichment broths can increase the probability of
isolating the organism. Intensive methods to detect Salmonella (pre-enrichment) are primarily
designed for food analysis but are sometimes used clinically, to resuscitate stressed organisms
and increase the probability that small numbers of organisms will be detected.
Salmonella spp. are identified with biochemical tests, and the serovar can be identified using
serology for the somatic (O), flagellar (H) and capsular (Vi) antigens. Phage typing or plasmid
profiling is also used for some serovars. Further characterization, if needed, can be carried out at
a reference laboratory.PCR and other genetic techniques may also be available.
Salmonellosis is common in humans, and the incidence of disease seems to be increasing. Large
outbreaks are sometimes reported in hospitals, institutions and nursing homes, or linked to
contaminated food. The rise in popularity of reptiles as pets has led to an increase in the number
of reptile-associated cases.It can affect all ages, but the incidence and severity of disease is
higher in young children, the elderly, and people who are immune-compromised or have
debilitating diseases. Children under 10 and immune-compromised persons seem to have an
increased risk of contracting severe disease from reptiles.
The overall mortality rate for most forms of salmonellosis is less than 1%; however, some
serovars or syndromes are more likely to be fatal. During outbreaks, approximately 10% of all
cases and 18% of cases in the elderly result in invasive disease.In these individuals (those that
fall within the high-risk group) or in normal persons exposed to an extremely high dose of the
Salmonella pathogen, the organism can invade the blood stream spreading throughout the body
and causing a profound illness. It can cause infection in other organs, including the spinal cord,
joints and blood vessels.
Little evidence exists that antimicrobial therapy reduces the severity or duration of salmonellosis.
It may instead prolong the carriage and is not recommended for acute salmonellosis in a normal
host.
The number of hospitalization and deaths that occur in association with unreported cases has not
been estimated. Modern techniques capable of tracking the epidemic episodes are often used in
research facilities but personnel in public health laboratories may not be aware of them. Hospital
data at time of discharge does not always have on record the number of hospitalizations due to
Salmonella and this is due to the fact that the laboratory tests done may not be available. At

times, problems exist as serotyping and antimicrobial resistance determinations are not
frequently performed and this can result in a misdiagnosis. For serotyping in particular, part of
the problem is maintaining supplies of high quality serotyping reagents.
This infection plays an important role in community health and particularly in food safety as
food products of animal origin are considered to be the major source of transmission to humans.
It may incur significant social and economic costs due to lost productivity and the impact on
industry and agriculture. Special programmes should therefore, be implemented for surveillance
of such products and informing individuals of how cross- contamination could be prevented as
well as the proper techniques in food preparation (hand washing and separation of vegetables)
because even healthy food handlers could be carriers. Manufacturing companies, farmers,
transporters etc., should also take proper steps to prevent the contamination during transport or
storage. They should also be inspected regularly to ensure that the different guidelines are being
followed. Young children should never be allowed to own pets like turtles and birds as these are
possible routes of transmission and they should also be taught proper hand washing techniques.
7. Figure 1. Salmonella surface antigens

The genus Salmonella consists of only two species: S. enterica and S. bongori. The latter
species, however, is very rare.
Members of the species Salmonella enterica can be divided into smaller groups (i.e., serotypes)
based on two structures on the cell surface: the O antigen and the H antigen. The O antigen is a
carbohydrate antigen in the lipopolysaccharide of the bacteriums outer cell membrane. The H
antigen is a protein antigen in the bacteriums flagella. (Figure 1)
O antigens and H antigens are detected using antisera that react with a single antigen or group of
related antigens. All Salmonella serotypes can be designated using a formula based on the O and
H antigens they express. Many serotypes are also given a name (e.g., Salmonella Typhimurium,
Salmonella Agona, Salmonella Muenchen). (NOTE: The serotype name is capitalized and not
italicized.)
Although extensive serotyping of surface antigens can be used for identification of a Salmonella
isolate, the reagents are costly, the process is time-consuming, and the results are not likely to
affect treatment of the individual patient. As a result, in many countries clinical laboratories
perform only a few O antigen reactions that allow them to group an isolate into broader, less
specific categories called serogroups. The isolate is then forwarded to a state or national
reference laboratory for complete serotyping.
There are over 2,500 recognized Salmonella serotypes. In 1995, Salmonella Enteritidis,
Typhimurium, and Typhi accounted for over three-quarters of the isolates reported in a global
survey.
Describe how serotype results can be used in public health practice.
Ans.: Serotyping depends on testing the organisms reaction with many different antibodies to
determine which antigens are present. Based on detection of antigens a single species can be
divided into hundreds of thousands of different serotypes. The utility of this system has helped to
expand the power of the public health surveillance system in that, outbreaks become more easily

detectable which were noted previously as sporadic cases and this helps the public health
authorities to investigate outbreaks by comparing the bacterial strains associated with different
cases of food borne disease. The development therefore, of this system with a centralized
database would enhance rapid detection of different clusters within a country and improve
international communication about theses outbreaks. Once a cluster of infection caused by
different strains has been identified, rapid epidemiological investigation will determine whether
the cluster is a true outbreak with a common source, how to combat such an outbreak and to
develop future prevention strategies.
8. As early as the mid-1980s, Salmonella became a pathogen of public health concern in the
Caribbean (Figure 2) when it caused an increasing number of cases and outbreaks of
diarrhea involving local and tourist populations. The communicable disease surveillance
system in place at the time, however, did not support the timely detection of these
outbreaks or the investigation of risk factors associated with infection. As a result, the
incidence of Salmonella continued to grow.
To detect outbreaks of infectious diseases (e.g., salmonellosis) and investigate risk factors
for infection, what characteristics should a communicable disease surveillance system
have?
Ans.: The characteristics of a communicable disease surveillance system are that it:
a. Health staff from multi-disciplines, either in government or non-government health
facilities.
b. Should contribute to an effective control of the disease.
c. Should have standards in terminology, reporting formats and methods in order to ensure
quality of the surveillance system and to enable easier/consumer friendly participation by
those involved.
d. Should have a record of prevailing incidence levels, impacts and trends to assist in the
development of feasible objectives for prevention and control of the diseases and the
evaluation of control programmes.
e. Should track epidemiologic patterns and risk factors associated with the diseases to assist
in the development of intervention strategies.
f. Should have a collection of sufficient, appropriate epidemiologic data on cases and
identify preventable cases.
g. Should be able to detect of outbreaks for the purpose of timely response, investigations
and effective implementation of control measures.
h. Should have timely transmission of these data from local to district Medical Officer of
Health, State and National (Disease Control Division, Ministry of Health) level for
analysis, interpretation & trending of the infectious disease pattern.
i. Should use the data obtained to enhance control programmes and assist in the development
of realistic objectives for reducing the number of preventable cases.
j. Should be evaluated periodically to test effectiveness and cost-benefit to access the
progress in the control of infectious diseases.
Figure 2. Countries of the Caribbean and surrounding land masses.

9. The communicable disease surveillance system in the Caribbean was based on notifiable

disease reports from physicians and other health care providers in the community (i.e.,
clinician-based reporting). Surveillance of most communicable diseases included both
laboratory-confirmed cases and cases diagnosed based on clinician suspicion. The
laboratory did not report cases of communicable disease to the surveillance system or
submit isolates for confirmation or further testing (e.g., serotyping).
To report a communicable disease in the Caribbean, the health care provider completed a disease
report card (Figure 3) and mailed it to the local health department within 7 days of diagnosis of
the patient.
Figure 3. Communicable Disease Case Report Card
CARIBBEAN EPIDEMIOLOGY CENTRE
Clinician-based Reporting
COMMUNICABLE DISEASE CASE REPORT
CARD
Case identification

Last name, First name, Middle initial:

Address:
City/Country:
Disease information
Diagnosis:
Lab-confirmed: Yes
Date of onset:

No

Attending physician
Name:
Address:
Telephone number:

Case information
Sex:
Male
Female
Age:
Current status:
Alive

Dead
Person reporting case (if not
attending physician)
Name:
Telephone number:

A clerk at the local health department reviewed the report cards for completeness (requesting
additional information from the health care provider, where needed), batched the reports, and
mailed them to the countrys Ministry of Health where they were sorted by disease. The
Ministry of Health forwarded the reports to the Caribbean Epidemiology Centre (CAREC).
An epidemiologist from CAREC reviewed and summarized the reports from the individual
countries. If necessary, the epidemiologist contacted the Ministry of Health if an unusual disease
pattern was noted. CAREC distributed weekly, quarterly, and annual communicable disease
reports for the region and each country to all Ministries of Health. In addition, CAREC reported
occurrences of selected diseases (e.g., cholera, plague, yellow fever) to the Pan American Health
Organization/World Health Organization as required by International Health Regulations.
Diagram the flow of information in the Caribbean communicable disease surveillance system.

Ans.:
PAHO/WHO

reports occurrences

COUNTRIES
of selected diseases
as required by
CAREC
international
contacts MOH
health

MOH OF ALL

epidemiologist

if unusual

regulations
is noted

MINISTERY OF HEALTH (MOH)

LOCAL HEALTH DEPARTMENT

disease pattern

report received &

if additional

HEALTH CARE PROVIDER

information is

needed the
clinician is
contacted

10. In an evaluation of the Caribbean communicable disease surveillance system, it was

determined that less than 40% of notifiable disease cases were actually reported by health
care providers. The average reporting delay (i.e., from diagnosis to receipt of the report by
CAREC) was 56 days.
Evaluate the Caribbean communicable disease surveillance system with respect to the
desired goals of outbreak detection and investigation of risk factors for infection. What
changes would you make to the surveillance system? Why?