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Based on the information below. Answer the following questions.

Describe the patterns that can be identified in the population impacted by the SARS outbreak.
Draw conclusions about the mode of transmission of the disease based on your analysis of the disease and population.

Student Role

The Epiville Department of Health — the site of your internship — has been abuzz with activity concerning an outbreak of unusual cases of pneumonia deaths among patients in the Epiville General Hospital. Your supervisor, Dr. Zapp, gives you an assignment: acquaint yourself with the Department’s surveillance and reporting systems and collect all available information about this outbreak.

Upon poring through the heavy folios in the Department’s library, you learn a lot of information about disease surveillance. In Epiville, all hospitals, physicians and laboratories are required to report any suspicious symptoms that could pose a potential health risk to the general public. These reports provide the valuable clinical and demographic data the Department needs for monitoring disease trends and public health intervention. Your new colleagues also clue you in to WEPI1 TV, which is the best place to hear the latest information about what’s happening in Epiville. As it so happens, Stew O’N eil did a piece on the new outbreak in last night’s news. You turn to the WEPI1 channel website to read the text file of his report.

Based on your own research and the newscast, you decide to look for the following background information on the internet:

Information about SARS on the Epiville Department of Health Website
Epiville Map from the Epiville Chamber of Commerce Website
SARS case definition from the World Health Organization (WHO) Website

Getting information from books and the net is fine, but Dr. Zapp tells you that nothing beats the fieldwork. She directs you to visit the Epiville General Hospital to do the preliminary work for the outbreak investigation.

Data CollectionInfectious Ward of the Epiville General Hospital

You begin your detective work with the infectious disease ward of the Epiville General Hospital. You start by reviewing the charts of patients who died from the mysterious disease. The administrator at the Admissions Office tells you that they suspect that this is severe acute respiratory syndrome (SARS), but the hospital has not yet received the materials to conduct diagnostic tests that could confirm these suspicions.

You decide to make a list with the names of the patients who have died from the mysterious disease, their symptoms upon admission to the hospital, symptom duration and if any patient family members became sick as well. You end up reviewing 12 charts of the patients who seem to have died from the same disease. Six persons were 60 and older, 4 persons were in the age range of 25 to 50, and 2 were children (3 and 11 years old). As you review the charts, you suddenly realize that all of the patients who died from the disease also happened to have the same street address and lived in the Amoy Apartment Complex. You decide to proceed by going over to their place of residence.

Amoy Apartment Complex

You arrive at the Amoy Apartment Complex and speak to Mr. Jones, one of the complex managers. Mr. Jones tells you that one tragedy after another has struck this set of buildings and people of all ages, young and old, are coming down with a severe flu and are dying. People are panicking and hardly anybody has left the building over the last three days. He has received 100 phone calls from tenants about breaking rent contracts. (The complex contains 200 apartments and serves a total of 600 residents.) Aside from those persons who have already passed away, there are 70 other people who have come down with similar respiratory flu-like symptoms. Most of these individuals were hospitalized at the nearby Epiville General Hospital. You take down the names of these people who reported being affected with flu-like symptoms and race back to the Department of Health.

Data AnalysisBack at the DOH :

You suspect that what you have on your hands is an outbreak of SARS. Before going any further with your investigation you need to get guidance from your supervisor. Dr. Zapp compliments you on the job well done and outlines the following steps of the outbreak investigation to aid your work:

Define the epidemic
Define the “numerator” (cases)
Define the “denominator” (population at risk for developing disease)
Calculate attack rates
Examine the distribution of cases by person, place, and time (PPT)
Look for combinations (interactions) of relevant variables
Develop hypotheses based on the following:
Existing knowledge (if any) of the disease
Analogy to diseases of known etiology
Test hypotheses
Further analyze existing data utilizing an appropriate study design
Collect additional data
Recommend control measures

You return to your modest cubicle at the DOH and eagerly embark upon the first steps of an outbreak investigation: descriptive analysis .

The epidemic should be characterized using the criteria in the case definition .

NOTE : Despite your hard work, no case definitions are perfect because of possible case misclassification. For instance, a diagnostic test may show that a person has the disease when in fact they do not (false positives), or conversely, that a person is free of disease when in fact he or she is truly infected (false negatives). It is very important to have reliable and valid diagnostic tools to decrease the number of false positives and false negatives. The costs of misdiagnosing a case and delaying the appropriate treatment, especially in the case of such a deadly infection as SARS, can be significant.

With your case definition at hand, you go back to the Epiville General Hospital to review the charts of the 70 persons who reside at the Amoy Apartment Complex. Based on your review of the charts, you confirm that 53 out of the 70 suspected cases in the apartment complex are most likely to be SARS cases. Out of the 17 patients who did not meet the case definition, 5 had similar symptoms as SARS cases but their chest X-rays were clear, others (6) recovered within a week (this was an indication that they just had flu), and the rest (6) had pneumonia of known etiology. All of these 53 individuals are alive and battling the disease. The case definition you came up with is remarkably similar to the case definition of SARS developed by the World Health Organization (WHO) in 2003.

You remember from your reading at the beginning of the day that surveillance is an essential feature of epidemiologic practice and is often divided into two “types”: passive and active. Most of the surveillance done on a routine basis is called passive surveillance. In passive surveillance , physicians, laboratories, and hospitals are required to report diseases from the list of reportable diseases (usually a list of 70-80 diseases) and are given the appropriate mailing forms and instructions, with the expectation that they will report all of the cases of reportable disease that come to their attention. Active surveillance requires periodic telephone calls or personal visits to the reporting individuals/hospitals/laboratories to obtain required data.

The next morning, you are eager to show your case definition and report on your visit to the Amoy Apartment Complex to your supervisor. Dr. Morissa Zapp compliments you on your good work and recommends that you contact two other hospitals in the city to see if they have similar cases that were not reported through passive surveillance. Your advisor’s suspicions are confirmed. There have been 3 suspicious deaths at the Star hospital. You set out to investigate  immediately.

The hospital administrator tells you that they had a 70 year old man admitted two weeks ago with respiratory symptoms, and that a doctor and nurse who were taking care of him got sick within a week of his admission. When the administration realized how contagious the disease was, the patient, doctor and nurse were put into isolation. Unfortunately, by the time extraordinary precaution measures were instituted, 20 additional staff members had become infected, including 5 medical residents. All of them had visited the patient’s room while attending the weekly rounds and may have had close physical contact with the patient. The hospital administration notified the DOH by a phone call about the situation, but failed to follow up with proper documents.

Employing your understanding of PPT, you decide to review the chart of the elderly man who was admitted to the hospital. His chart reveals that he lives in the Amoy Apartment Complex. Several days before he got ill, on August 1, 2003, he had attended an annual luau party held in the garden of the Amoy Apartment Complex. Approximately 300 other tenants also attended.

Now that you have gathered information on all the suspected SARS cases, you are ready to make a spot map 

Now that you have mapped out all the cases according to the place of residence, you are ready to do some data analysis. The best measure to use in describing an epidemic is cumulative incidence . Cumulative incidence is calculated as the number of new cases over a defined study period, divided by population at risk over that period. Cumulative incidence is usually expressed per 100, per 1,000, per 10,000, or per 100,000.

he Amoy Apartment Complex is located in Area B, the Star Hospital is located in Area C, the staff of 110 persons who works at the Star Hospital resides all over Epiville and Epiville suburbs.

b 65 cases were hospitalized at the Epiville General Hospital and 1 case was hospitalized at the Star Hospital.

c 22 cases from the Star hospital include only staff members. Hospital staff reside in different areas of Epiville.

Disease transmission refers to any mechanism by which an infectious agent is spread from a source or reservoir to another person. The mechanisms, or modes of transmission , are divided into two categories: direct and indirect. For instance, a disease can be transmitted from person to person by means of direct contact (e.g., influenza). Indirect transmission usually occurs through a common vehicle (e.g., contaminated air or a contaminated water supply) or through a vector such as a mosquito]. 

Outbreak Control

Just as you are going over your descriptive analysis, Dr. Zapp calls you in your office to let you know that the SARS diagnosis has been confirmed for all 12 dead cases from the Amoy Apartment Complex. Your primary goal now is to plan an effective outbreak management .

During the outbreak management it may be necessary to take the following measures: quarantine (isolate a person until he or she is no longer infectious), isolate contacts, and conduct additional surveillance (passive and active).

 

 

 

 

 

 

 

SCIENCE
HEALTH SCIENCE
NURSING
HEALTHCARE IHP 330

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