Milgrid Guzman

Professor Christine Hahn, MPH

Epidemiology (HSC 410) - 202021 Fall O1_OnLine

Case Study Cholera

Case Study Questions

1. Concerning John Barnes, what are the modes of disease transmission and what the

epidemiologic terms by which they are identified ?

The mode of transmission was through fomite and the epidemiologic terms that they are

identified were through the water of the sewers and canals.

2. How long is a fortnight ?

Fortnight is two weeks long.

3. In the examples or circumstances presented, what were the various modes of

transmission stated or at least alluded to? Which were correct? Which were incorrect

and why? What role did personal hygiene and sanitation (including food preparation

and hand-washing) play in the transmission of the disease and continuation of an

outbreak?

The first primary mode of transmission was person-to-person or touching, having

contact with another person. The other form of transmission is effluvia given off from a

sick person to another person. It supposedly started in the canal, and people’s personal

hygiene was not good back in the day because they really didn’t wash their hands in

which it transferred in to the food and got the food contaminated, and it transferred to
 the people and got them sick with cholera going to their bowels and stomachs. It was

also transferred through clothing and the bed linens that carried cholera. Most of the

drinking water was infected with cholera that people were drinking and got them sick as

well.

4. Several instances of causal association were presented or alluded to in the examples

presented in the case. List the various instances of association you can identified from

the examples or situations presented in the case. What role did social class, poverty, and

housing arrangements play in association? What role did water play in association ?

There were several different instances of causal association that were presented and or

alluded to the case, in which they were in the food that was infected by people who had

cholera, in the water infected by feces and the cholera evacuations that was then used

for cooking and drinking in which then also infected people. Also, within the

involuntary passage of evacuations from infected individuals that carried cholera.

Within the social being poor or being in poverty was one of biggest risk-factor for the

spread of cholera due to the fact that poor people lived in very tight living arrangements

that had been cooking and eating all together then it was spread throughout also

because it was not clean and they didn’t wash their hands properly that also helped

spread cholera.

5. Describe cholera, first as presented by John Snow and then as it is known today.

John Snow described cholera as a disease that was transmitted through a person who

had it to a healthy person, it was first discovered at sea through the sea ports, then
 transmitted by touch, and communication , also through ingestion which then spread to

the stomach and bowels. As it is known today cholera is an illness that is caused by an

infected intestine by the bacteria vibrio cholera, the severe type of infection is horrific

diarrhea, leg cramps and vomiting that also causes a huge weight loss and lots of bodily

fluids that cause dehydration and can lead to shock in ultimately can kill a person if not

treated properly.

6. What hypotheses were developed by John Snow about the cause (etiology), signs and

symptoms, spread and course of the cholera ? How do the observations and hypotheses

of Snow conform with modern understanding and knowledge of cholera?

The hypothesis that was developed by John Snow was that cholera was a morbid

material that entered through the alimentary canal. It then transferred to the stomach and

bowels where the type of material then reproduced and became an irritant. Which then

the poison/cholera takes fluids away from the blood that circulates in a person’s body

and through the capillaries. Snow also hypothesized that cholera can be also transmitted

through infected water that people drank and people touching one another.

7. Contrast to those who develop cholera with those who do not.

The difference between people who developed cholera was that if people lived in

poverty, they are most likely to get cholera due to living in a tight housing, and they

didn’t have the proper ways of keeping themselves clean so they where most likely to
 get cholera and the people who were in a higher upper class, they had the proper means

to keep themselves cleaned and they didn’t live so tight together.

8. What epidemiological phenomenon can be observed in Locksbrook (near Bath)

example?

The epidemiological phenomenon that can be observed in the Locksbrook (near Bath)

example is that cholera was transmitted through contaminated water that was one of the

sources, and it was not transmitted through people by touching one another.

1. What are the time factors and implications for this case? Explain the time lag from

attacks in Figure I-2 to deaths in Figure I-3.

The time factors and implications for this case is that cholera can spread very rapidly

with the incubation period that is very short, it takes about twenty-four to forty eights

hours for it to occur. In the figures I-2 and I-3 with the time lag shows that the deaths

and attacks, in which the attacks usually happen withing one to two days before the

onset of death.

2. What are the place factors and implications for this case? Compare the workhouse to the

brewery to the pub. Discuss migration and its effect on the epidemic. What place issues

are important to this case ?

The place factors and implications for this case where that the closer that people lived

to the pump it affected them with cholera, the areas that didn’t get cholera was the
 workhouse and the brewery because they used water that came from a deep well so the

people who drank from there didn’t get cholera. Also, migration did have its adverse

effect on cholera with people moving to try to avoid getting it with the hopes that they

also didn’t spread anymore.

3. What did the people who got the disease do differently than those who did not get the

disease (e.g., the inmates in the workhouse) ?

The difference that they is that they did not drink the water from the pump on the Broad

street, they ended up drinking from other pumps. The people who did not get sick also

went or migrated to other places that did not have cholera, to keep themselves safe.

4. From Figure I-2, what is the index case? What date is the beginning of the epidemic?

What other time factors are discerned from this chart? How did Snow establish the time

of onset ?

From the Figure I-2 the index case date was on August thirty first, and the pandemic

time frame where from August thirty first and September first. Within the time lag there

is a period that occurred between the deaths and the attacks. The pandemic occurred so

rapidly because of the migration that people did in order to protect themselves and they

also had taken the pump handle off so the cholera would stop from spreading and

getting more people sick.

5. What accurate observations were made about wells, cesspools, and ground water, purity

of the water, and its contamination? What inaccurate and misunderstood observations

were made about the water, its flow, and its contamination?

The observation that was made is that the wells had holes and were broken or cracked

that also gave passage to cholera that then made the water contaminated. Also, the other

means of waters such as sewage, streams and the ground water in which also became

contaminated as well. The observations that were also made from the cesspools was that

if they didn’t get emptied then it was leaked in which then it will penetrate to the

springs and other water resources that were surrounding them. The impure source that

was in the large amount chlorides, it was also observed was that the animalcules that

had the organic matter was still living.

6. What evidence did Snow use to establish the fact that a cholera epidemic was

occurring? Did Snow clearly demonstrate the cause and source of the outbreak of

cholera in the Golden Square area? Explain.

The evidence that Snow used to establish the facts that a cholera epidemic was

occurring was by using a map to plot the locations of cholera that was occurring in

certain areas around the Broad street pump. He also did surveys by talking to the people

who did survived or didn’t get cholera, and the relatives of the people who did pass

away, and the other people who do not even get cholera in order for him to make his
 observations. Snow did also take some samples from the Golden Square area pump and

it smelled very nasty and there was a certain film around it as well.

7. What were Snow's initial and basic hypotheses concerning the epidemic? What

processes and procedures did Snow use to establish his hypotheses about the outbreak ?

Snow’s initial and basic hypotheses concerning the epidemic was that the cholera

epidemic source was because of the water. He then formed his hypothesis by talking to

people such as friends, family members and the patients to find out about their water

sources. He then observed through his hypotheses that the poison or bacteria was

plotted in order to observe where it was located throughout the epidemic in order to

track the cholera.

8. The obvious control measure applied was the removal of the handle from the Broad

street pump. What role did the removal of the pump handle play in the decline of the

epidemic ? Did the removal of the pump handle have an effect on the control epidemic ?

What other social and political roles did removing the handle from the pump play ?

The role of the removal of the pump handle played a huge decline of the pandemic

because it actually reduced the spread of cholera. The removal of the handle also did

have a effective control on the pandemic because it reduced it significantly, the social

and political roles that came into play was that by removing the handle showed all the
 politicians that due to the epidemiological information that Snow provided was very

helpful to the public in reducing the cholera.

1. Compare the person characteristics of the households that received their water from the

different water suppliers.

The comparison of the cases was a reflect of the people that had passed away due to

cholera, in the very first seven weeks of the cholera epidemic; they also lived in the

districts that were receiving their water supply from the Lambeth, Southwark and

Vauxhall water companies. The cholera cases were all compared to how many people or

the number of the households in the districts so they can be able to calculate all the

deaths per every ten thousand households.

2. Concerning the water supply system and structure from the two different water

companies, explain the soundness of the research approach. Is this a descriptive or

analytic epidemiologic research design ?

When concerning the water supply system and the structures from the two different

water companies the districts were getting their water supply from the same water

suppliers, then Snow was able to get a comparison in order to compare the deaths that

where cause due to cholera based on where people got their water supply, in which

allowed him to explain the difference between them. The research design is a
 comparison group that is involved so therefore it would be considered as a analytic

epidemiologic study research design.

3. What were some of the practical problems and barriers that Snow faced which slowed

his inquiry of the cholera epidemic of 1854 ? How would this relate to modern-day

epidemiological investigations ?

The practical problems and barriers that Snow faced in which slowed his inquiry of the

cholera epidemic of 1854 was that people did not know who was their water supplier,

so Snow then had to ask the landlords and get the paid receipts in attempting to track it

down, but it was not all accessible. He then started to test the water supply through a

series of different chemical test in order to determine which water supply was it. In

which the accurate information on which water supplier people where using, this helped

get the real results and it should always be a priority to help people in epidemiological

investigations.

4. "As the epidemic advanced, the disproportion between the number of cases in houses

supplied by the Southwark and Vauxhall Company and those supplied by the Lambeth

Company became not quite so great. . . ." From an epidemiological point of view, why

was this so? Give detailed epidemiological reasoning and discussion addressing person,

place, and time issues.

 From an epidemiological point of view, I believe that it was because of the

contaminated water from both Vauxhall and Southward water company suppliers. Due

to the fact that it was not common for cholera to be transmitted by touch or person to

person. Throughout the epidemic cholera was spreading or being transmitted most

likely because of the workers that had serviced at the Lambeth water company were

exposed to the waters in the other homes of the other people that were serviced by the

Vauxhall and Southwark water companies those were the issues that they were facing

throughout the epidemic.

1. What did Snow observe regarding the association between city size and the length of

the epidemic ?

Snow observed regarding the association between the city size and the length of the

epidemic was that the period or the duration of cholera in a certain place it was in a

direct proportion to the number of the population throughout the epidemic.

2. Snow suggested several reasons for the failure of contaminated water to produce disease

in all who consume it. Why is it that not everyone became sick or died when they

consumed cholera-causing bacterium Vibrio cholera ?

The reason that not everyone became sick or died when they consumed the cholera-

causing bacterium was because of boiling the water would kill the bacteria cholera, in

which also the certain amount of the cholera in the water throughout any given time will
 have a big impact in the chances of the intake. Also, the bacterium Vibrio cholera

would sink to the bottom of the water supplies if it was left alone in which not everyone

became sick or died when they consumed it.

3. Which of Snow's observations about time and seasons and their effects on epidemics

were correct and which were incorrect ? Why ?

The observations about time and seasons that Snow made was that it would increase in

the latter part of the summer, so people where drinking more in the summer so the

primary source of cholera was due to the fact that by drinking more water and eating

more foods that were contaminated with the bacterium cholera. Even the flies were

spreading it as well, the spike in the summers where one of the main seasons and it was

correct due to the number of people who were getting sick around that particular time

period and season.

4. Several different theories and hypotheses have been presented. Which of these are

consistent with known scientific and biomedical knowledge and common sense ?

Which of these are not ? Why ?

The several different theories and hypothesis that have been presented are:

a. The poison of cholera was believed that it was in the air when people contracted it

that was in the required in the existence of the magnesian salts and or calcareous , in

which the drinking water gave it to the existence of it.

b. The other different theory was the elevation on the ground in which it was

throughout the effluvia communication that the patient was passing it through the

air in which it was inhaled by other people into their lungs and got the sick with it.

c. The other different theory was an unidentified substance in the environment or

atmosphere that was localized, with the gas that was from vegetables and animals

that were rotting.

The different theories where based on common sense and the biomedical and

scientific knowledge that they had at that point in time. It was until the water was

tested for cholera through chemical to determine if the bacterium was in the waters

from certain water company suppliers. The pumps were also tested to determine if

the bacterium was there especially from the people who had passed away from that

particular water pump.