Assignment: Food Poisoning Outbreak at Bluegrass Hospital

Name: ______________________________________ Due: _________ Case Study: Food Poisoning Outbreak at Bluegrass Hospital An outbreak of food poisoning occurred among the 300 staff and patients at Bluegrass Hospital a few hours after eating dinner. Among the 50 people who became ill, the symptoms were mainly nausea, vomiting, and diarrhea. The infection-control public health official investigated the outbreak and reported results in the table below: Foodborne Outbreak at Bluegrass Hospital Consumed Food (exposed) Did Not Consume (not exposed) Type of Food No. People No. Ill No. People No. Ill Apple juice 50 10 250 40 Cantaloupe 30 6 270 44 Taco salad 100 30 200 20 Hot dogs 80 20 220 30 Chipped beef with 80 45 220 5 sauce Egg salad Apple pie Layer cake 90 120 125 20 20 25 210 180 175 30 30 25 Answer the following questions: 1. Calculate the crude attack rate (# sick/total exposed * 100%). Hint: Refer to case study above for numerator and denominator. 2. Calculate food-specific attack rates (in %) using data in table above. Place results in table below. Type of Food Apple juice Cantaloupe Taco salad Hot dogs Food-Specific Attack Rates (in %) Consumed Food (exposed) Did Not Consume Food (not exposed) Example: (10/50) * 100% = 20% (40/250) * 100% = 16% Risk Ratio (exposed/not exposed) 20/16 = 1.4 Chipped beef with sauce Egg salad Apple pie Layer cake 3. Compare the above rates and calculate a risk ratio (consumed/not consumed) – see examples. Note: risk ratio is NOT a percent. Compare the ratios for each food item. Which food is the most likely cause of this “common source” outbreak? Explain your reasoning based on the risk ratios. 4. What was the incubation period (suspected exposure time to time of symptoms) based on information about the outbreak in the case study? 5. Do some research on causes of bacterial food borne outbreaks and see if you can find an example of bacteria that would be suspected based on the incubation period and symptoms. Limit your search to the following bacterial causes of food borne diseases: E. coli, Salmonella, Shigella, Campylobacter, Staphylococcus aureus. Make a table showing organism, incubation range, typical signs/symptoms. Use www.cdc.gov for research. Organism causing foodborne disease E.coli Typical incubation period Typical signs/symptoms Salmonella Shigella Campylobacter Staphylococcus aureus (foodborne only) What is the most likely cause based on incubation period and symptoms? Name: _________________________________________________ Antibiotics and Antibiotic Resistance What do you think of when you hear the term ‘antibiotic’? When does a person need an antibiotic? Do you go to healthcare providers because you think you need an antibiotic? Has the healthcare provider ever told you there was no need for an antibiotic? Was this explained to you? When you get an antibiotic, for how long do you take it? Do you ever stop taking it for any reason? Are you aware of antibiotic allergies that you may have? Do healthcare providers ask you about them? When does resistance to antibiotics occur? Research this… Assignment: Food Poisoning Outbreak at Bluegrass Hospital

What are some mechanisms whereby bacteria become resistant to antibiotics? Research this… In viewing the film, what is the ‘big deal’ about resistance? Aren’t there ‘backups’? What did you learn from the film (take-away message)? Why don’t pharmaceutical companies emphasize antibiotic research? What is the role/responsibility of healthcare providers in dealing with the antibiotic resistance problem? Name: print____________________________________ Sign: _______________________________ Assignment: Disease Transmission – Outbreak Help received: Draw an Epidemic Curve: A local health officer in a small community received reports from three physicians about patients who had diarrhea, abdominal cramps, vomiting, chills, and fever. From stool samples (feces) collected from several patients, a Salmonella species was isolated. A total of 119 patients were eventually identified in the community. The times of onset of the disease and numbers of ill persons were recorded as follows over a three-day period: January 7 Time # of ill persons January 8 Time # of ill persons January 9 Time # of ill persons 6-7 am 2 12-1 am 5 12-1 am 3 8-9 am 5 2-3 am 3 2-3 am 2 10-11 am 11 4-5 am 3 4-5 am 0 12-1 pm 18 6-7 am 3 6-7 am 1 2-3 pm 10 8-9 am 4 8-9 am 0 4-5 pm 7 10-11 am 6 10-11 am 1 6-7 pm 5 12-1 pm 8 12-1 pm 0 8-9 pm 4 2-3 pm 4 2-3 pm 0 10-11 pm 4 4-5 pm 3 6-7 pm 3 8-9 pm 2 10-11 pm 2 a. Make a graph showing an epidemic curve with Time on the x-axis and # of ill persons on the yaxis (use Excel to make the graph, label all axes). DO NOT MAKE three curves (eg, don’t do the three dates separately). You should have ONE epidemic ‘curve’, not three. b. Your graph should show two peaks. If this graph represents a common source, single exposure outbreak, what do you think the second, smaller peak represents? c. Can the incubation period be determined from the data given? Why or why not? Name: Due: Assignment: Read the following articles on Book Shelf: 1) “Public health threat of new emerging and neglected zoonoses in the industrialized world” List and describe examples. 2) Read two articles on Book Shelf related to pregnancy and infectious diseases Why are pregnant women considered ‘at risk’? Describe reasons why this is so. Make sure that your examples are specific. Do research on why it is important that pregnant women get vaccinated against influenza. For this, use www.cdc.gov Morbidity and Mortality Weekly Report (MMWR) Length: about 1.5 to 2 pages (double spaced) The n e w e ng l a n d j o u r na l of m e dic i n e review article global health Globalization, Climate Change, and Human Health Anthony J. McMichael, M.B., B.S., Ph.D. T he global scale, interconnectedness, and economic intensity of contemporary human activity are historically unprecedented,1 as are many of the consequent environmental and social changes. These global changes fundamentally influence patterns of human health, international health care, and public health activities.2 They constitute a syndrome, not a set of separate changes, that reflects the interrelated pressures, stresses, and tensions arising from an overly large world population, the pervasive and increasingly systemic environmental impact of many economic activities, urbanization, the spread of consumerism, and the widening gap between rich and poor both within and between countries. In recent decades, international connectivity has increased on many fronts, including the flow of information, movements of people, trading patterns, the flow of capital, regulatory systems, and cultural diffusion. These exponential increases in demographic, economic, commercial, and environmental indexes have been labeled the Great Acceleration.3 Remarkably, the resultant environmental effects are now altering major components of the Earth system.4,5 Assignment: Food Poisoning Outbreak at Bluegrass Hospital

The current geologic epoch is being called the Anthropocene (successor to the Holocene epoch)5,6 in recognition of the global force that Homo sapiens has become, pushing or distorting Earth’s great natural global systems beyond boundaries considered to be safe for continued human social and biologic well-being.4,7 The loss of biodiversity, the greatly amplified global circulation of bioactive nitrogen compounds, and humaninduced climate change have already reached levels that are apparently unsafe.4 These changes pose fundamental threats to human well-being and health.4,7 For example, a positive relationship has been observed between regional trends in climate (rising temperatures and declining rainfall) and childhood stunting in Kenya since 1975, indicating that as projected warming and drying continue to occur along with population growth, food yields and nutritional health will be impaired.8 These human-induced climatic changes often act in concert with environmental, demographic, and social stressors that variously influence regional food yields, nutrition, and health. Furthermore, at the current level of global connectedness and interdependence, the environmental impact of human activity has a wider geographic range, although its influence may be offset somewhat by more effective global alerts and more rapid distribution of food aid. The extreme heat and wildfires in western Russia in the summer of 2010 destroyed one third of that country’s wheat yield, and the subsequent ban on exported grain contributed to a rise in the price of wheat worldwide, exacerbating hunger in Russia (where flour prices increased by 20%) and in low-income urban populations in countries such as Pakistan and Egypt.9,10 On the economic front, the recent global financial crisis has underscored the domino-like interdependence of national economies. n engl j med 368;14 nejm.org From the National Centre for Epidemiology and Population Health, Australian National University, Canberra, ACT, Australia. Address reprint requests to Dr. McMichael at the National Centre for Epidemiology and Population Health, Australian National University, Canberra, ACT 0200, Australia, or at tony.mcmichael@anu.edu.au. N Engl J Med 2013;368:1335-43. DOI: 10.1056/NEJMra1109341 Copyright © 2013 Massachusetts Medical Society. april 4, 2013 The New England Journal of Medicine Downloaded from nejm.org by EILEEN HINKS on October 31, 2013. For personal use only. No other uses without permission. Copyright © 2013 Massachusetts Medical Society. All rights reserved. 1335 The n e w e ng l a n d j o u r na l Increases in interpopulation connectivity and increases in scale and intensity of action and impact Demographic Changes Economic Activity Trade and capital mobility Labor conditions Wealth creation and distribution International aid: financial and health care Social Changes Institutions, governance, international codes Cultural diffusion Impacts on Population Health Large-Scale and Systemic Environmental Impacts Degradation of land and water Depletion of resources Ecosystem disturbances Disruption of biogeophysical systems (e.g., climate system) Figure 1. Assignment: Food Poisoning Outbreak at Bluegrass Hospital

Influence on Human Health of Changes Related to Globalization. The figure is a schematic representation of the three major domains — social, economic, and environmental — within which globalizing processes and changes are occurring. Shown are their main components, the two-way interactions between them, and the central fact that all three domains influence the conditions for and levels of population health. In particular, changes in population size, distribution, mobility, levels and types of economic activity, and global flows of capital and labor all have consequences for the environment, including the recent rapid increase in greenhouse-gas emissions as the primary cause of current climate change. Those great contemporary ­environmental changes have diverse and far-reaching consequences for ­human health. Effec t s of Gl ob a l i z at ion on P opul at ion He a lth Global influences on population health such as those described above transcend the more specific, focused frame within which international health issues are addressed.2 The processes of global change are more systemic, involving disruption or depletion (not merely local pollution). Remediating or adapting to these changes requires an understanding of dynamic systems, their complexity and associated uncertainties, and coordinated policy responses across relevant sectors. The relationships between these perva1336 m e dic i n e sive processes of change and human health are shown in Figure 1. Globalization and Global Changes Population growth Urbanization, increased density Aging Increased mobility Family structures of n engl j med 368;14 Demographic Changes Population growth is often overlooked in the discourse on global change, including its relation to the mitigation (abatement) of climate change, to which the contribution of global emissions is obvious.11 The projections by the United Nations that today’s population of 7 billion will increase to 9.3 billion by 205012 should reactivate the debate about whether we can succeed in pursuing realistic objectives for a healthy climate without curtailing the actual number of humans pressing on the environment. Furthermore, the negativefeedback loop of excessive population pressure on regional environments (involving soil exhaustion, water depletion, and the loss of various wild animal and plant food species) not only exacerbates various ongoing worldwide environmental and ecologic changes but also entrenches conditions of poverty and disadvantage. In these latter circumstances, fertility rates tend to remain high. Some additional increase in the world population is inevitable in countries with high fertility rates, given the demographic flywheel momentum of populations weighted toward the young. Meanwhile, moderate gains have been made in facilitating education for girls, although progress in this, as well as in the provision of adequate education about reproduction and reproductive choice, remains slow in many low-income countries.13 Where unplanned pregnancy rates remain high (e.g., Timor-Leste and Nigeria), so do risks to maternal and child health. Social Changes and Economic Activity Many other aspects of globalization influence population health,2 including the accelerated emergence of new infectious diseases,14,15 the near-ubiquitous rise in the rates of obesity and associated noncommunicable diseases as daily bodily energy budgets (food energy input vs. physical energy output) shift into surplus,16 the spread of cigarette marketing, the effects of climate change,17,18 increases in resistance to antimicrobial agents, and health risks in the workplace due to the deregulation of international labor markets.2 Looming large in the background as additional determinants of health are the persistent, even increasing, disparities in wealth, education, autonomy, and social inclusion.19 There are, of course, certain aspects of globalization nejm.org april 4, 2013 The New England Journal of Medicine Downloaded from nejm.org by EILEEN HINKS on October 31, 2013. For personal use only. No other uses without permission. Copyright © 2013 Massachusetts Medical Society. All rights reserved. Global Health that are beneficial to health, such as the enhanced flow of information, improvements in internationally coordinated vaccination programs and systems to respond to infectious diseases, and a greater capacity for long-distance responses to disasters. Adverse global influences on health, such as rising food prices and extended ranges of some infectious diseases, have also impeded attainment of the United Nations Millennium Development Goals.20 Future global health goals must be better integrated with the fundamental influences of poverty, inequity, illiteracy, climate change, land-use patterns, and food insecurity on health. After the Rio+20 Conference (2012), the Millennium Development Goals are to be replaced by Sustainable Development Goals in 2016, Assignment: Food Poisoning Outbreak at Bluegrass Hospital

reflecting the principle set forth at the original Rio Declaration on Environment and Development (1992) that concern for humans must be at the center of sustainable development. Nevertheless, concern for human health is not yet near that center. This reflects the continuing misperception of what health means and the dominance of a narrow, clinically based view that seemingly does not take into account the fundamental need, in improving population health, to address the poor fit between environmental and sociocultural conditions and basic human biologic and psychological needs. Environmental and Ecologic Changes The deep-seated, essentially ecologic risks to population health cannot be countered effectively at the local level alone. Climate change induced by human activities, for example, is due to the globally aggregated excess of greenhouse emissions. Primary prevention of health problems arising from such global environmental and sociodemographic changes therefore requires coordinated international policy, supplemented by more local policy-making and action. For example, the World Trade Organization should give greater priority to averting the adverse health and environmental effects of international free trade.21 There is also a need for instruments similar to the WHO Framework Convention on Tobacco Control1,22 and the WHO Global Outbreak Alert and Response Network, in relation to the emergence of infectious diseases,23 as well as the United Nations Environmental Programme Montreal Protocol to protect the ozone layer.24 The following four examples describe other n engl j med 368;14 environmental and ecologic changes on a global scale that will increasingly influence the world’s health. First, the probability that new strains of influenza virus will emerge is increasing, particularly in the rural villages of Southeast Asia and East Asia.14,25 The risk increases with population growth; the juxtaposition of traditional backyard pig, chicken, and duck farming with intensified commercial poultry production; and environmental changes that affect the flight paths of migrating wild birds. Second, the decline in available seafood protein (which is important for many low-income coastal populations) is a threat to health and reflects the unprecedented combination of ocean warming, acidification (due to increased uptake of carbon dioxide), deoxygenation,26 destruction of coastal fish nurseries, and overfishing.27 Third, diverse health risks are posed by the deprivation, displacement, and conflict that result from shortages of fresh water.8,28 Many populations, such as those in Bangladesh, Vietnam, Egypt, and Iraq, live downstream on great rivers that traverse several countries. In many cases, river flows are threatened by the loss of glacier mass and snowpack due to global warming and by the increased diversion of flow by neighbors upstream. Finally, the need to maintain food supplies and adequate nutrition for the increasing world population presents a major challenge.29 Global food production also faces pressures as a result of reduced yield due to land degradation, water shortages, and climate change and the rising demand for animal foods among middle-income populations. Furthermore, agriculture (especially livestock production) accounts for around one fourth of global greenhouse-gas emissions.30 Thus, there are growing pressures to transform food production (e.g., more mixed cropping and inclusion of acceptable genetically modified crops), distribution, and consumption. Since the environmental, particularly climatic, effects of producing red meat from methane-producing ruminants (e.g., cattle, sheep, and goats) are so great, thought needs to be given to the question of whether production of this protein source will need to be curtailed — while allowing a sufficient increase to ensure safe childhood nutrition in the many poorer populations, which currently consume levels of red meat that are lower than those in the overconsuming rich populations by a factor of 10.30 The global food security issue is nejm.org april 4, 2013 The New England Journal of Medicine Downloaded from nejm.org by EILEEN HINKS on October 31, 2013. For personal use only. No other uses without permission. Copyright © 2013 Massachusetts Medical Society. All rights reserved. 1337 The n e w e ng l a n d j o u r na l further complicated by the ongoing land grab in eastern Africa and elsewhere by richer countries seeking investment opportunities and self-insurance against future land, food, and biofuel shortages (e.g., Middle Eastern oil-producing states, China, and South Korea).31 These four examples also confirm that, in a world of global and systemic changes, these individual changes for the most part do not impinge on population health in isolat …