Professional Documents
Culture Documents
Epidemic asthma
Learning objectives:
1. Developing a case definition
2. Interpreting descriptive data
3. Constructing histograms
4. Plotting the distribution of cases
5. Constructing 2x2 tables
6. Calculating risk ratios (odds ratios)
7. Identifying intervention strategies for prevention
PART 1 - INTRODUCTION
Number
165
128
138
124
Question 6: Print the attached graph paper and draw a bar-chart of the data tabulated
above in Table 2. What additional information does the bar-chart provide?
Graph Paper
Day
Number
14
15
16
17
18
19
Table 3.
Age, sex, time and place of onset of illness, for each of the persons who came
to the emergency room with acute asthma on 21/01/1986.
Ag Se Time of
e x onset
41
28
27
40
30
19
17
40
28
49
47
29
28
38
49
59
39
40
59
41
10
27
27
20
27
18
30
48
30
F
M
M
F
F
F
F
M
M
M
F
M
F
M
F
M
M
M
M
M
M
F
M
F
M
F
M
M
F
10:55
12:50
13:40
12:00
13:25
02:20
11:05
17:15
13:50
17:10
14:30
11:10
14:30
11:35
18:20
22:10
11:25
11:05
21:20
11:08
23:15
12:05
12:40
09:25
11:40
12:30
12:15
16.50
12:25
Place of
onset
(Region)
4
2
2
3
2
3
2
1
2
1
1
2
2
1
3
6
1
1
3
10
7
2
2
8
2
2
2
2
2
40
41
28
48
29
30
27
57
28
30
29
29
50
30
41
40
57
47
58
41
48
69
40
27
47
89
49
29
19
3
10
2
1
2
2
2
2
2
2
2
2
2
2
4
2
2
2
2
4
2
2
2
2
2
2
2
2
1
M
M
F
F
M
M
F
M
M
F
F
M
M
F
M
F
F
M
M
F
F
M
F
F
M
M
F
F
F
10:00
10:08
13:30
16:30
13:10
13:15
14:05
14:40
14:50
11:25
14:20
14:10
14:15
14:25
12:55
15:25
15:05
15:40
15:50
11:50
15:30
15:10
15:25
13:05
16:50
12:10
15:20
12:20
17:20
29
37
38
39
40
37
41
40
37
38
38
39
39
40
15
18
70
18
50
F
M
M
M
M
F
M
M
M
M
F
F
M
M
F
M
M
F
M
13:20
12:17
12:35
12:25
12:05
11:30
12:08
19:15
10:17
10:35
10:45
10:25
10:25
10:05
23:25
00:50
15:15
00:30
11:15
2
1
1
1
1
1
10
6
1
1
1
1
1
1
6
3
2
7
2
67
40
29
78
68
19
38
48
37
49
38
40
59
60
19
20
47
67
28
F
F
F
F
M
F
M
F
M
M
F
F
M
M
M
M
M
M
M
12:30
17:25
11:20
11:30
12:45
12:25
18:50
18:30
11:17
19:10
11:45
19:25
11:25
11:00
05:10
06:15
15:30
16:40
11:50
1
1
2
2
1
1
1
10
1
3
1
7
1
3
3
8
1
2
2
Question 9: Print the attached graph paper and draw a bar-chart of the cases by hour of
occurrence (Table 3). What hypotheses are suggested?
Graph Paper
PART 2
In your discussions with emergency room personnel, you learn that this is not the first time that
the hospitals have been overwhelmed with patients suffering from acute asthma attacks. You are
told that "asthma epidemic days" have occurred on 12 other occasions during the last 2 years.
Noting the clustering of asthma emergency room visits in space and time, you request data on air
pollution in the city during the past two years. For Tuesday 21 January, air pollution levels were
below normal for the city. The 24-h average level of sulphur dioxide was 54 g/m3 and that of
black smoke was 98 g/m3. The highest hourly mean for nitrogen dioxide was 10 ppb. Twentyfour hour pollen and spore counts were also below average for that time of year. Meteorologic
data showed high atmospheric pressure and stagnancy of the air with a very low wind speed.
Question 10: What conclusions can you draw from this information?
Since many persons reported that they were affected in the centre of the city, near the waterfront,
you decide to find out more information about the activities there. You learn that the following 8
products were either loaded or unloaded from barges and books in the harbour during the last
two years.
Coal
Cotton
Gasoline
Soybeans
Fuel oil
Coffee
Corn
Butane
Question 11: How would you use this information to further explore this problem?
You ask for dates on which each of these products were loaded or unloaded from barges or boats.
This information is shown in Table 4.
Table 4
Days Product is Handled
(Loaded or Unloaded)
Product
NO
YES
NO
YES
196
521
150
567
10
180
537
11
399
318
300
417
135
582
12
249
13
468
140
577
12
Coal
Fuel Oil
Gasoline
Cotton
Coffee
Corn
Soybeans
Butane
Question 12: Using the information in Table 4, print and complete the following tables and
calculate a risk ratio and confidence interval (C.I) for each table (use the formulas
presented in class discussion. Also, the computer software EPIINFO will be demonstrated
to calculate confidence intervals).
No
Yes
No
Day
No
No
Unloading Soybeans
(1)
Yes
No
Yes
No
Epidemic
Asthma
Yes
Yes
Day
Day
No
No
Unloading Gasoline
Unloading Soybeans
(2)
Yes
Epidemic
Asthma
Yes
Epidemic
Asthma
Yes
Day
Epidemic
Asthma
Unloading Corn
Yes
No
Yes No
Epidemic
Asthma
Yes
Day
Day
No
No
Unloading Cotton
Yes
Epidemic
Asthma
Unloading Butane
No
Yes No
Epidemic
Asthma
Yes
Yes
Day
Day
No
No
Unloading Coffee
Yes
Epidemic
Asthma
No
Yes
Day
No
Question 13: How do you interpret the risk ratios and confidence intervals you have
calculated?
Question 14: Now substitute a 1.0 for the 0 in cell B (soybeans) and re-calculate.
Question 15: How would you proceed from here?
PART 3
Question 16: Develop a strategy for prevention of asthma epidemics in the city.
Question 17: How would you assess the costs of this prevention strategy compared to the
costs of the emergency visits for asthma attacks?
Based on a report by Anto, J.M. et al. Community outbreaks of asthma associated with inhalation of soybean dust.
The New England Journal of Medicine, 1989, 320(17): 1097-1102
For further study of methodology for epidemiologic studies of asthma, the following review article is recommended:
Anto, J.M. & Sunyer, J. Epidemiologic studies of asthma epidemics in Barcelona. Chest, November, 1990
(Supplement): 185s-189s.