FS3120 – Food Safety & Toxicology

Practice Exam Question

Outbreak Calculations
By: M. Abdurrahman Mas
Email: muhammad.mas@i3l.ac.id
 Steps in an Outbreak Investigation - I

• When you are tasked with an outbreak investigation you first need to
CLASSIFY what kind of outbreak you’re dealing with
• Then it would help for you to match the symptoms with the food item(s) by
creating a timeline of events
• Depending on the class of outbreak you will then need a different set of
information
• For Point Source you need to calculate the various attack rates
• For the diffuse you need to calculate the odds ratio
 Steps in an Outbreak Investigation - II

• Classification of outbreaks:
• Point source outbreak
• Localized outbreak - Usually family or community event
• Where a known number of people attended an event and a known number of people
consumed each suspected food
• Usually multiple suspected foods in the event with many clinical symptoms
• Diffuse outbreak
• Dispersed cases in a large geographical area - Diseases can be continuous or intermittent
• Usually first reported by health authorities
• Where the number of people that consumed the suspected food is continuously growing,
• The number of people will be for a given time period
• Usually 1 suspected food item with many clinical symptoms
 Steps in an Outbreak Investigation - II

• Creating a timeline:
• When tackling any outbreak case you need to know
which foods is likely to cause which disease Agent Incubation Time Symptom
• One way to do this is by figuring out the time since
exposure until symptoms first appear
Nausea, vomiting, stomach
• For the exam we will be using “fake” agents (real A 1-2 hours
agents will be more difficult) irritation

• For example, using the table to the right: Severe diarrhea, stomach
• If a food item is served at 10:00 AM and the B 2 - 4 hours on the average
cramp
symptoms of nausea appears at 12:00, then it is
likely that A is the agent
• If a food item is served at 10:00 AM and the C
10 till 48 hours, generally in
Fever, weakness, malaise
symptoms of diarrhoea appeared at 12:00, it is likely 24 hours
to be agent B as opposed to agent A
• If a food item is served at 10:00 AM and the
symptoms of fever appeared the next day at 12:00,
it is likely to be agent C
• This can be used for both Point Source and
Diffuse Outbreaks
 Point Source vs. Diffuse outbreaks
Point Source Outbreaks Diffuse Outbreaks: Exposed Unexposed

• Attack rate 𝑎 𝑏 With

• Crude attack rate =

• 𝑂𝑑𝑑𝑠 𝑟𝑎𝑡𝑖𝑜 = ൗ Disease
a b
𝑐 𝑑 Without
𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑝𝑒𝑟𝑠𝑜𝑛𝑠 𝑖𝑙𝑙 𝑤𝑖𝑡ℎ 𝑡ℎ𝑒 𝑑𝑖𝑠𝑒𝑎𝑠𝑒 • Where: disease
c d
𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑝𝑒𝑟𝑠𝑜𝑛𝑠 𝑎𝑡𝑡𝑒𝑛𝑑𝑖𝑛𝑔 𝑡ℎ𝑒 𝑒𝑣𝑒𝑛𝑡 • a =exposed with disease
• Will show how many people are suspected to be • b = unexposed with disease
diseased • c = exposed with no disease
• Attack rate = • d = unexposed with no disease
𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑝𝑒𝑟𝑠𝑜𝑛𝑠 𝑖𝑙𝑙 𝑤𝑖𝑡ℎ 𝑡ℎ𝑒 𝑑𝑖𝑠𝑒𝑎𝑠𝑒 𝑤𝑖𝑡ℎ𝑖𝑛 𝑡ℎ𝑒 𝑡𝑖𝑚𝑒 𝑝𝑒𝑟𝑖𝑜𝑑
𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑝𝑒𝑟𝑠𝑜𝑛𝑠 𝑎𝑡 𝑟𝑖𝑠𝑘 𝑤𝑖𝑡ℎ𝑖𝑛 𝑡ℎ𝑒 𝑡𝑖𝑚𝑒 𝑝𝑒𝑟𝑖𝑜𝑑 • If odds > 1 then it is likely that
• Will show how many people are presumed to be exposure to the material causes
diseased disease
• Food Attack rate = • If odds = 1 then it is equally likely that
𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑝𝑒𝑟𝑠𝑜𝑛𝑠 𝑖𝑙𝑙 𝑡ℎ𝑎𝑡 𝑎𝑡𝑒 𝑎 𝑐𝑒𝑟𝑡𝑎𝑖𝑛 𝑓𝑜𝑜𝑑 exposure or no exposure to the
𝑇𝑜𝑡𝑎𝑙 𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑝𝑒𝑜𝑝𝑙𝑒 𝑤ℎ𝑜 𝑎𝑡𝑒 𝑎 𝑐𝑒𝑟𝑡𝑎𝑖𝑛 𝑓𝑜𝑜𝑑 material causes disease
• Will show how likely a food item is to be the cause • If odds < 1 then it is unlikely that
of the disease exposure to the material causes the
disease
 Example Question – Point Source Outbreak I

• A group of students attended a sports events where they ate a few snacks
made by the students at home. The number of students that attended this
study session was 15 students. The first snack was a chocolate bar at 8:00,
there were 5 students ate the chocolate bar. Later on at 12:00 another 5
students drank boba. And finally the last snack was pudding that was
consumed by the last 5 students at 16:00.
• Throughout the day, however some students started getting sick, 2
students complained of nausea at 9:00 AM, 4 students started complaining
of cramps at 14:00 AM and 1 student suffered a fever the next day
• Which food is responsible for which illness and what are the attack rates?
 Example Question – Point Source Outbreak II

• If we use the table to the right we can gather

enough information that: Agent Incubation Time Symptom
• Chocolate bar had agent A
• Boba had agent B
• Pudding had agent C A 1-2 hours
Nausea, vomiting, stomach
irritation
• This is based on the timing of the symptoms
and type of symptoms matching the agent in Severe diarrhea, stomach
question B 2 - 4 hours on the average
cramp
• It may help you to make a timeline to make sure
everything lines up 10 till 48 hours, generally in
• Note how many people ate what, and how many C
24 hours
Fever, weakness, malaise
people had symptoms
• Now that we have the agents and numbers of
people for each agent/ food we can calculate
the attack ratios
 Example Question – Point Source Outbreak III

𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑝𝑒𝑟𝑠𝑜𝑛𝑠 𝑖𝑙𝑙 𝑤𝑖𝑡ℎ 𝑡ℎ𝑒 𝑑𝑖𝑠𝑒𝑎𝑠𝑒

1. Crude attack rate =
𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑝𝑒𝑟𝑠𝑜𝑛𝑠 𝑎𝑡𝑡𝑒𝑛𝑑𝑖𝑛𝑔 𝑡ℎ𝑒 𝑒𝑣𝑒𝑛𝑡
𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑝𝑒𝑟𝑠𝑜𝑛𝑠 𝑖𝑙𝑙 𝑤𝑖𝑡ℎ 𝑡ℎ𝑒 𝑑𝑖𝑠𝑒𝑎𝑠𝑒 2
1. Agent A = = = 0.13
𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑝𝑒𝑟𝑠𝑜𝑛𝑠 𝑎𝑡𝑡𝑒𝑛𝑑𝑖𝑛𝑔 𝑡ℎ𝑒 𝑒𝑣𝑒𝑛𝑡 15
𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑝𝑒𝑟𝑠𝑜𝑛𝑠 𝑖𝑙𝑙 𝑤𝑖𝑡ℎ 𝑡ℎ𝑒 𝑑𝑖𝑠𝑒𝑎𝑠𝑒 4
2. Agent B = = = 0.27
𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑝𝑒𝑟𝑠𝑜𝑛𝑠 𝑎𝑡𝑡𝑒𝑛𝑑𝑖𝑛𝑔 𝑡ℎ𝑒 𝑒𝑣𝑒𝑛𝑡 15
𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑝𝑒𝑟𝑠𝑜𝑛𝑠 𝑖𝑙𝑙 𝑤𝑖𝑡ℎ 𝑡ℎ𝑒 𝑑𝑖𝑠𝑒𝑎𝑠𝑒 1
3. Agent C = = = 0.07
𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑝𝑒𝑟𝑠𝑜𝑛𝑠 𝑎𝑡𝑡𝑒𝑛𝑑𝑖𝑛𝑔 𝑡ℎ𝑒 𝑒𝑣𝑒𝑛𝑡 15
𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑝𝑒𝑟𝑠𝑜𝑛𝑠 𝑖𝑙𝑙 𝑡ℎ𝑎𝑡 𝑎𝑡𝑒 𝑎 𝑐𝑒𝑟𝑡𝑎𝑖𝑛 𝑓𝑜𝑜𝑑
2. Food Attack rate =
𝑇𝑜𝑡𝑎𝑙 𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑝𝑒𝑜𝑝𝑙𝑒 𝑤ℎ𝑜 𝑎𝑡𝑒 𝑎 𝑐𝑒𝑟𝑡𝑎𝑖𝑛 𝑓𝑜𝑜𝑑
𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑝𝑒𝑟𝑠𝑜𝑛𝑠 𝑖𝑙𝑙 𝑡ℎ𝑎𝑡 𝑎𝑡𝑒 𝑎 𝑐𝑒𝑟𝑡𝑎𝑖𝑛 𝑓𝑜𝑜𝑑 2
1. Choco = 𝑇𝑜𝑡𝑎𝑙 𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑝𝑒𝑜𝑝𝑙𝑒 𝑤ℎ𝑜 𝑎𝑡𝑒 𝑎 𝑐𝑒𝑟𝑡𝑎𝑖𝑛 𝑓𝑜𝑜𝑑 = 5 = 0.4
𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑝𝑒𝑟𝑠𝑜𝑛𝑠 𝑖𝑙𝑙 𝑡ℎ𝑎𝑡 𝑎𝑡𝑒 𝑎 𝑐𝑒𝑟𝑡𝑎𝑖𝑛 𝑓𝑜𝑜𝑑 4
2. Boba = 𝑇𝑜𝑡𝑎𝑙 𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑝𝑒𝑜𝑝𝑙𝑒 𝑤ℎ𝑜 𝑎𝑡𝑒 𝑎 𝑐𝑒𝑟𝑡𝑎𝑖𝑛 𝑓𝑜𝑜𝑑 = 5 = 0.8
𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑝𝑒𝑟𝑠𝑜𝑛𝑠 𝑖𝑙𝑙 𝑡ℎ𝑎𝑡 𝑎𝑡𝑒 𝑎 𝑐𝑒𝑟𝑡𝑎𝑖𝑛 𝑓𝑜𝑜𝑑 1
3. Pudding = 𝑇𝑜𝑡𝑎𝑙 𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑝𝑒𝑜𝑝𝑙𝑒 𝑤ℎ𝑜 𝑎𝑡𝑒 𝑎 𝑐𝑒𝑟𝑡𝑎𝑖𝑛 𝑓𝑜𝑜𝑑 = 5 = 0.2
In this particular case, the food attack and the attack rate refer to the same probability,
since the number of people who consumed the food product is known
 Example Question – Diffuse Outbreak - I

• The health authorities have identified the food product produced by your
company is suspected to be causing an outbreak across Indonesia. They
have identified 150 cases of illness of which 100 people reportedly
consumed your product amongst others in the past 2 months. After a
more thorough analysis by your sales department, they have identified
that at least 200 products have been sold in the past 2 months.
• The health authorities provided the following statistics for you to analyse:
• Illness X – 50 total patients, 35 people who reported to have eaten your food, 15
people who have not eaten
• Illness Y – 100 total patients, 65 people who reported to have eaten your food, 35
people who have not eaten
• Calculate the odds ratio of your food product for each disease and
whether it is likely your food is the culprit
 Example Question – Diffuse Outbreak - I

Illness X Illness Y
Variable # Meaning Variable # Meaning
a 35 Sick with illness X and ate your product
a 65 Sick with illness Y and ate your product
b 15 Sick with illness X but didn't eat your product
Sick with illness Y but didn't eat your
b 35
product

c 165 Not sick with illness X but ate your product c 135 Not sick with illness Y but ate your product
Not sick with illness X and did not eat your product Not sick with illness Y and did not eat your
d 35
(Sick with illness Y and did not eat your product) product
d 15
Odds 0.5 Unlikely to be the cause (Sick with illness X and did not eat your
product)
Odds 0.2 Unlikely to be the cause
 Summary

• Steps in solving an outbreak question:

1. CLASSIFY what kind of outbreak you’re dealing with
2. Create a timeline/ Match symptoms with food(s)
3. Depending on the class of outbreak you will then need a different
set of information
1. For Point Source you need to calculate the various attack rates
2. For the diffuse you need to calculate the odds ratio