Obtain Background Information · Define the Problem · Formulate Hypothesis · Develop a Study to Clinical approach deals with an individuals

ls with an individuals and families. Although it has been criticized for devoting Endemic Disease - Present at a continuous level
Test the Hypothesis · Collect Data and Observations · Evaluate Results · Determine if Hypothesis insufficient attention to prevention, clinical medicine is not inherently tied to curative, rather than preventive throughout a population/geographic area; constant
is true/modify – Do lab verification to prove hypothesis · Formulate Conclusions · Report Results approaches. In fact, in recent decades the time and resources devoted to preventing disease have greatly presence of an agent/health condition within a given
increased, especially in the realm of secondary prevention. Pediatrics has long emphasized primary prevention. geographic area/population; refers to the usual
Diagnostic inquiry is directed at the patient. The scope of inquiry is primarily the prevention and treatment of prevalence of an agent/condition.
medically recognized diseases. Epidemic - Large numbers of people over a wide
Public Health Approach: The public health approach deals with communities. The public health approach geographical area are affected.
emphasizes prevention, means preventing the occurrence of disease in individuals. The distinction between Pandemic - An epidemic occurring over several
prevention and cure may not be as clear. The scope of public health is much broader than that of the clinical countries or continents and affecting a
approach, because there is no framework of a clinical encounter to confine the time for diagnosis or large proportion of the population.
intervention, and the variety of people and their situations in a community multiply the range of factors that Index Case - First patient in an epidemiological study
can affect health. (also known as patient zero or primary case).
Latent Period - Time in between when a person comes
1. Oral briefing – inform local health officials or other need-to-know groups as soon as information is into contact with a pathogen and when they become
available infected.
2. Written report – usually done in scientific format for future reference, legal issues, and education

Thirteen Steps to Investigating an Outbreak:

-Remember that this is a conceptual order, so steps have to be done simultaneously!
-Prepare for field work
-Establish the Existence of an Outbreak - Consider Severity, Potential for Spread, Public -
Concern, and Availability of Resources
-Verify the Diagnosis
-Construct a Working Case Definition
-Find Cases Systematically and Record Information
-Describe and Orient the Data in Terms of Person, Place, and Time - Descriptive -
Epidemiology
-Develop Hypotheses (Agent/Host/Environment Triad) = Chain of Transmission
-Evaluate Hypotheses - Analytical Studies (MUST Have a Control Group)
-Refine Hypotheses if Necessary
-Compare and Reconcile with Laboratory and/or Environmental Studies
-Implement Control and Prevention Measures (ASAP!)
-Initiate or Maintain Surveillance
-Communicate Findings

Incidence rate is calculated by dividing the total

Passive surveillance is effective because it casts a wide net and can be more easily conducted on an on-going number of new cases of a specific disease in a
basis. It is useful for routine surveillance activities. However, it may result in underreporting and incomplete data. specified period, usually one year, by the average
Active surveillance should be used to investigate diseases with a high risk to the public's health, but it can also be number of people in the population during the
resource intensive. Data collected through active surveillance generally provides more accurate and complete same period.
information than passive surveillance. Syndromic surveillance might be used to identify illness clusters early in
order to mobilize a rapid response. Syndromic surveillance might be used to identify illness clusters early (even
There are three levels of prevention: Primary
before diagnoses are confirmed and reported) in order to mobilize a rapid response. Outbreak surveillance is
prevention, Tertiary Prevention, and Secondary
mostly active and is used to find additional cases to pinpoint the source of the outbreak. Risk factor surveillance
prevention. Primary prevention is when you
might be used to identify an increased risk of illness due to specific environmental, behavioral, or biological
improve the overall health of a population.
elements. Sentinel Surveillance. A sentinel surveillance system is used when high-quality data are needed
Secondary Prevention reduces the impact on a
about a particular disease that cannot be obtained through a passive system.
disease or injury that has already occurred.
Finally, Tertiary Prevention improves the
treatment and recovery of someone.

For Food Borne

Illnesses, prevention
tactics include: Cook
meat, poultry, and eggs
thoroughly. Don't cross-
The purpose of the CDC strategy is to prevent and control diseases, injuries and contaminate one food
Ecological studies are often used to measure prevalence and incidence of with another. Chill and
disabilities. They do this by Expanding and coordinating surveillance systems for the
disease, particularly when disease is rare. A cross-sectional study is refrigerate leftovers
early detection, tracking, and evaluation of emerging infections in the United States.
defined as an observational research type that analyzes data of variables promptly. Clean and
They also Improve surveillance for reportable infectious diseases by reevaluating wash all produce.
current reporting mechanisms and requirements and providing technical and financial collected at one given point of time across a sample population.
Report suspected
assistance to state health departments., Create population-based Emerging Infections foodborne illnesses to
Epidemiology and Prevention Centers to complement and support local, regional, and Null Hypothesis- a general statement or default position that there is no the local health
national surveillance and research efforts, Expand the use of Sentinel Surveillance relationship between two measured phenomena. department.
Networks to complement other surveillance methods for detecting and monitoring
emerging infections, Expand field investigative and epidemic response capabilities,
Assess and apply innovative tools to facilitate collection, analysis, and dissemination 1. Temporality – cause/exposure must precede effect/outcome
of infectious disease surveillance information, Develop more effective international 2. Consistency – observation of association must be repeatable in different populations at different times
surveillance networks for the anticipation, recognition, control, and prevention of 3. Coherence, 1-1 relationship – exposure is always associated with outcome/ outcome is always caused by the Selection Bias occurs when study subjects are selected for the study as a result
emerging infectious diseases, Improve surveillance and rapid laboratory identification specific exposure of a third unmeasured variable which is associated with both the exposure and
to ensure early detection of antimicrobial resistance, Develop and evaluate tools for 4. Strength of association – relationship is clear and risk estimate is high the outcome. Recall Bias: In a case control study, patients do not remember
the reliable and rapid detection of antimicrobial resistance, Determine risk factors for 5. Biological plausibility – biological explanation makes sense exposures that they do not believe caused the disease as well as those they
emergence of resistance through applied epidemiologic research, Strengthen and 6. Dose/response (biologic gradient) – increasing risk is associated with increasing exposure believe did cause it (cases) and they don't recall some exposures as clearly as
integrate programs to monitor and prevent emerging infections associated with cases (controls). Information bias: Occurs from systematic error in the
food/water, new technology, and environmental sources, and many, many more. Skin and Secretions- acts as initial barrier, mucus catches pathogens, enzymes kill pathogens. assessment of a variable.
Inflammatory Response- injury/tissue damage releases chemical signal, blood flow increases: heat, redness,
Active Immunity- occurs when the person is exposed to a live pathogen, develops the pain, swelling A variety of microorganisms can cause disease. Pathogenic organisms
disease, and becomes immune as a result of the primary immune response Phagocytosis- ingests and destroys microorganisms: neutrophils, macrophages are of five main types: viruses, bacteria, fungi, protozoa, and worms.
Passive Immunity-short-term immunization by the injection of antibodies, such as Natural killer cells- kill tumor cell and infected cells with viruses Protozoa (also protozoan, plural protozoans) is an informal term for
gamma globulin, that are not produced by the recipient's cells. Naturally acquired Interferon- infected cell makes protein and releases into bloodstream interferes with reproduction. single-celled eukaryotes, either free-living or parasitic, which feed on
passive immunity occurs during pregnancy, in which certain antibodies are passed from organic matter such as other microorganisms or organic tissues and
the maternal into the fetal bloodstream. debris.
Herd Immunity- protecting a whole community from disease by immunizing a critical Parasitic worm: A worm classified as a parasite. (A parasite is a
mass of its populace. Vaccination protects more than just the vaccinated person. By Vector Transmission - no entry ----  Portals of Entry to the Nervous System - the brain is typically fairly
resistant to bacterial infection. There are four common portals of entry to the nervous system. For an organism to disease-causing organism that lives on or in a human or another animal
breaking the chain of an infection’s transmission, vaccination can also protect people and derives its nourishment from its host.)
who haven’t been immunized. But to work, this protection requires that a certain take advantage of these routes, they must display increasingly specialized adaptations as read from first to last:
parenteral, via the blood, via the lymphatic systems, and up the peripheral nerve axons. Ordering of blood and Pathogenic fungi are fungi that cause disease in humans or other
percentage of people in a community be vaccinated.
lymphatic system was arbitrary and not intended to imply that one serves as a significantly more difficult portal to organisms.
take advantage of than the other.
Infectivity - capacity to cause infection in a susceptible host
Skewedness - Distributions that have a few extreme values on the higher side are skewed to the right. It is the shedding of virus -- and particularly asymptomatic viral shedding -- Pathogenicity - capacity to cause disease in a host
Distributions that have a few extreme values on the lower side are skewed to the left. that is responsible for the transmission of genital Virulence - severity of disease that the agent causes to host
Peaks - If a distribution has no peaks, it is uniform. If it has one peak, it is unimodal. If it has two peaks, it
This study source was downloaded by 100000862834311 from CourseHero.com on 10-03-2023 21:07:37 GMT -05:00 herpes. Asymptomatic viral shedding is the presence of virus in the absence
is bimodal. of clinical signs or symptoms.
Normal distributions - A set of data that is unimodal, symmetrical, and continues off to infinity on both The basic reproductive ratio, R0, is defined as the expected number
tails. Also known as a Gaussian distribution. In the normal distribution, the mean, median, and mode are of secondary infections arising from a single individual during his or her
all the same. Technically, the normal distribution is continuous and infinite but can be approximated with entire infectious period, in a population of susceptibles.
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discrete values.
 Ecological - comparisons of geographical locations
Study Designs Advantages Disadvantages Cross Sectional - a survey,health questionnaire, "snapshot in
time"
Case-Control - compare people with and without disease to find
common exposures
Time Consuming Cohort - compare people with and without exposures to see what
Most Scientifically Sound Unethical for Harmful happens to each
Trial Exposures Randomized Controlled Trial - human experiment
Best Measure of Exposure
Most Expensive Quasi Experiments - research similarities with traditional
experimental design or RCT, but lack element of random
assignment to treatment/control
Most Accurate Observational Study
Time Consuming
Good Measure of Exposure
Expensive ^^^ 2x2
Cohort Study Correct Time Sequence
Bad for Rare Diseases contingency
Good for Rare Exposures
Possible Loss of Follow-up Table
Easy Risk Calculation

Can Study Rare Diseases

Possible Time-Order
Relatively Less Expensive and Confusion
Case-Control Study Relatively Fast
Error in Recalling Exposure
Good for Rare Diseases
Only 1 outcome
Good for Long Latency Periods

Fastest Possible Time-Order

Confusion
Cross-Sectional Study Least Expensive
Least Confidence in
Good for more than 1 Outcome Findings

Odds Ratio - used in case-control study, (a*d)/(b*c)

Relative Risk - used in cohort study, (a/(a+b))/(c/(c+d))
Point source Attack Rate - the rate that a group experienced an outcome or illness
outbreaks equal to the number sick divided by the total in that group. (There should
(epidemics) be a high attack rate in those exposed and a low attack rate in those
unexposed.)
For the exposed: (a)/(a+b)
For the unexposed: c/(c+d)

POINT SOURCE OUTBREAKS (EPIDEMICS) - involve a common source, such as contaminated food or a n
infected food handler, and all the exposures tend to occur in a relatively brief period. Consequently, point
source outbreaks tend to have epidemic curves with a rapid increase in cases followed by a somewhat
slower decline, and all of the cases tend to fall within one incubation period. The graph above from a
hepatitis outbreak is an example of a point source epidemic. The incubation period for hepatitis ranges from
15-50 days, with an average of about 28-30 days. In a point source epidemic of hepatitis A you would expec t
the rise and fall of new cases to occur within about a 30 day span of time, which is what is seen in the grap h
below.
Continuous common source
epidemics
Chi-square test
Hill's Criteria for Causation:
Strength of Association - relationship is clear and risk estimate is high
Consistency - observation of association must be repeatable in
different populations at different times
Specificity - a single cause produces a specific effect
Alternative Explanations - consideration of multiple hypotheses before
making conclusions about whether an association is causal or not
Temporality - cause/exposure must precede the effect/outcome
Dose-Response Relationship - an increasing amount of exposure
increases the risk
Biological Plausibility - the association agrees with currently accepted
understanding of biological and pathological processes
Experimental Evidence - the condition can be altered, either
prevented or accelerated, by an appropriate experimental process
Coherence - the association should be compatible with existing theory
and knowledge, including knowledge of past cases and epidemiological
studies
Five Step Process for Surveillance
-Identify, define, and measure the health problem of interest
-Collect and compile data about the problem (and if possible,
factors that influence it)
-Analyze and interpret these data
A chi-square is a statistical measure used to determine the difference between an expected -Provide these data and their interpretation to those responsible
value and an observed value. In epidemiology, it can be used to compare information from for controlling the health problem
different groups (i.e. age) to a local or national average. -Monitor and periodically evaluate the usefulness and quality of
χ2=∑(O−E)2E surveillance to improve it for future use. Note that surveillance of
a problem does not include actions to control the problem

Sensitivity and specificity are ways to calculate the chance of having a specific disease given you do or do
not have a disease. Nosocomial Disease - An infection
that is acquired in a hospital.
Fomite - A physical object that
serves to transmit an infectious
Z-Test- Used to compare two means when the
agent from person to person.
Has Has no population variances are known and the sample size is
disease disease greater than 30
T-Test- Used to compare two means when sample size
is greater than 30 The process begins with the
Paired T-Test- Used to compare multiple sets of data appropriate exposure to or
Fischer's Exact Test-Fischer's test searches for non- accumulation of factors sufficient for
random associations between two categorical variables. the disease process to begin in a
People who McNemar's Test-The McNemar Test is similar to a Chi- susceptible host. For an infectious
a b Square, except that it uses matched paired data. disease, the exposure is a
test positive
Maentel Haenszel Test- The Cochran-Maentel- microorganism. For cancer, the
Haenszel Test aims to find the association between exposure may be a factor that
variables while controlling for confounding. initiates the process, such as
ANOVA- The analysis of variance test, or ANOVA, is a asbestos fibers or components in
statistical measure used to compare two or more tobacco smoke (for lung cancer), or
Continuous common source epidemics may also rise to a peak and then fall, but the cases do not all occur means. one that promotes the process, such
People who
within the span of a single incubation period. This implies that there is an ongoing source of contamination. c d as estrogen (for endometrial cancer).
test negative
The down slope of the curve may be very sharp if the common source is removed or gradual if the outbreak is
allowed to exhaust itself. The epidemic curve below is from the cholera outbreak in the Broad Street area of After the disease process has been
London in 1854 that was investigated by Dr. John Snow. Cholera has an incubation period of 1-3 days, and triggered, pathological changes then
even though residents began to flee when the outbreak erupted, you can see that this outbreak lasted for more occur without the individual being
than a single incubation period. This suggests an ongoing source of infection, in this case the Broad Street Sensitivity is the chance of testing positive if you do have the disease. The equation to use for sensitivity aware of them. This stage of
pump. is: (a)/(a+b) subclinical disease, extending from
the time of exposure to onset of
Specificity is the chance of testing negative if you do not have the disease. The equation to use for disease symptoms, is usually called
specificity is: (d)/(d+b) the incubation period for infectious
diseases, and the latency period for
chronic diseases. During this stage,
Food (F) – There are sufficient nutrients available that promote the growth of microorganisms. Protein-rich foods, such disease is said to be asymptomatic
as meat , milk, eggs, and fish are the most susceptible. (no symptoms) or inapparent. This
Acidity (A)- Foodborne pathogens require a slightly acidic pH level of 4.6-7.5, while they thrive in conditions with a pH period may be as brief as seconds for
of 6.6-7.5. The United States Food and Drug Administration's (FDA) regulations for acid/acidified foods require that the hypersensitivity and toxic reactions to
Propagated (or food is to be brought to pH 4.5 or below. as long as decades for certain
progressive source) Time (T) - Food should be removed from "the danger zone" (see below) within two-four hours, either by cooling or chronic diseases. Even for a single
heating. While most guidelines state two hours, a few indicate four hours is still safe disease, the characteristic incubation
epidemic.
Temperature (T) - Food-borne pathogens grow best in temperatures between 41 to 135 °F (5 to 57 °C), a range referred period has a range. For example, the
to as the temperature danger zone (TDZ). They thrive in temperatures that are between 70 to 104 °F (21 to 40 °C). typical incubation period for hepatitis
Oxygen (O) - Almost all foodborne pathogens are aerobic, that is requiring oxygen to grow. Some pathogens, such as A is as long as 7 weeks. The latency
Clostridium botulinum, the source of botulism, are anaerobic. period for leukemia to become
evident among survivors of the
Moisture (M) - Water is essential for the growth of foodborne pathogens, water activity (aw) is a measure of the water
atomic bomb blast in Hiroshima
available for use and is measured on a scale of 0 to 1.0. Foodborne pathogens grow best in foods that have aw between ranged from 2 to 12 years, peaking at
0.95 and 1.0. FDA regulations for canned foods require aw of 0.85 or below. 6–7 years.

Vector - An animal that The onset of symptoms marks the

transmits disease. For transition from subclinical to clinical
example, a mosquito is a disease. Most diagnoses are made
vector for malaria. during the stage of clinical disease. In
Propagated (or progressive source) epidemic. The epidemic curve shown below is from an outbreak of Zoonosis - An infectious some people, however, the disease
measles that began with a single index case who infected a number of other individuals. (The incubation period disease that is transmissible process may never progress to
from animals to humans. clinically apparent illness. In others,
for measles averages 10 days with a range of 7-18 days.) One or more of the people infected in the initial wave
the disease process may result in
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infected a group of people who become the second wave of infection. So here transmission is person-to- Symptomatic - Showing
illness that ranges from mild to
person, rather than from a common source. Propagated epidemic curves usually have a series of successively symptoms or signs of injury.
severe or fatal. This range is called
larger peaks, which are one incubation period apart. The successive waves tend to involve more and more Asymptomatic - Showing no the spectrum of disease. Ultimately,
people, until the pool of susceptible people is exhausted or control measures are implemented. This is an ideal signs or symptoms, although the disease process ends either in
example, however; in reality, most of these epidemics do not produce the classic pattern. can be carrier of disease. recovery, disability or death.
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