Exercise 1.

1
Below are four key terms taken from the definition of epidemiology,
followed by a list of activities that an epidemiologist might perform.
Match the term to the activity that best describes it. You should match
only one term per activity.

A. Distribution
B. Determinants
C. Application
b
_____ 1. Compare food histories between persons with Staphylococcus food poisoning
and those without
b
_____ 2. Compare frequency of brain cancer among anatomists with frequency in
general population

:
_____ 3. Mark on a map the residences of all children born with birth defects within 2
miles of a hazardous waste site

_____ 4. Graph the number of cases of congenital syphilis by year for the country
c
_____ 5. Recommend that close contacts of a child recently reported with
meningococcal meningitis receive Rifampin
a
_____ 6. Tabulate the frequency of clinical signs, symptoms, and laboratory findings
among children with chickenpox in Cincinnati, Ohio

Check your answers on page 1-81

Introduction to Epidemiology
Page 1-6
 Exercise 1.2
In August 1999, epidemiologists learned of a cluster of cases of
encephalitis caused by West Nile virus infection among residents of
Queens, New York. West Nile virus infection, transmitted by mosquitoes, had never before
been identified in North America.

Describe how this information might be used for each of the following:

1. Assessing the community’s health

2. Making decisions about individual patients

3. Documenting the clinical picture of the illness

4. Searching for causes to prevent future outbreaks

Check your answers on page 1-81

Introduction to Epidemiology
Page 1-14
 Exercise 1.3
Match the appropriate core function to each of the statements below.

A. Public health surveillance

B. Field investigation
C. Analytic studies
D. Evaluation
E. Linkages
F. Policy development

9
_____ 1. Reviewing reports of test results for Chlamydia trachomatis from public health
clinics
e
_____ 2. Meeting with directors of family planning clinics and college health clinics to
discuss Chlamydia testing and reporting
f
_____ 3. Developing guidelines/criteria about which patients coming to the clinic
should be screened (tested) for Chlamydia infection
b
_____ 4. Interviewing persons infected with Chlamydia to identify their sex partners
d
_____ 5. Conducting an analysis of patient flow at the public health clinic to determine
waiting times for clinic patients
C
_____ 6. Comparing persons with symptomatic versus asymptomatic Chlamydia
infection to identify predictors

Check your answers on page 1-82

Introduction to Epidemiology
Page 1-20
 Exercise 1.4
Investigators of an outbreak of trichinosis used a case definition with the
following categories:

Clinical Criteria

Confirmed case: Signs and symptoms plus laboratory confirmation

Probable case: Acute onset of at least three of the following four features: myalgia,
fever, facial edema, or eosinophil count greater than 500/mm3
Possible case: Acute onset of two of the four features plus a physician diagnosis of
trichinosis
Suspect case: Unexplained eosinophilia
Not a case: Failure to fulfill the criteria for a confirmed, probable, possible, or
suspect case

Time: Onset after October 1, 2004

Place: Metropolitan Atlanta
Person: Any

Using this case definition, assign the appropriate classification to each of the persons
included in the line listing below. Use the highest rate classification possible. (All were
residents of Atlanta with acute onset of symptoms in November.)

Last Facial Eosinophil Physician Laboratory

ID # Name Myalgias Fever Edema Count Diagnosis Confirmation Classification

1 Anderson yes yes no 495 trichinosis yes confirmed

__________

2 Buffington yes yes yes pending possible pending probable

___________
trichinosis

3 Callahan yes yes no 1,100 possible pending probable

___________
trichinosis

4 Doll yes yes no 2,050 EMS* pending probable

___________

5 Ehrlich no yes no 600 trichinosis not done possible

___________

*Eosinophilia-Myalgia Syndrome

Check your answers on page 1-82

Introduction to Epidemiology
Page 1-28
 Exercise 1.5
Consider the initial case definition for SARS presented on page 1-26.
Explain how the case definition might address the purposes listed below.

1. Diagnosing and caring for individual patients

2. Tracking the occurrence of disease

3. Doing research to identify the cause of the disease

4. Deciding who should be quarantined (quarantine is the separation or restriction of

movement of persons who are not ill but are believed to have been exposed to infection,
to prevent further transmission)

Answers :

Check your answers on page 1-82

Introduction to Epidemiology
Page 1-29
 Exercise 1.6
Using the data in Tables 1.5 and 1.6, describe the death rate patterns for
the “Unusual Event.” For example, how do death rates vary between men
and women overall, among the different socioeconomic classes, among
men and women in different socioeconomic classes, and among adults and
children in different socioeconomic classes? Can you guess what type of situation might
result in such death rate patterns?

Table 1.5 Deaths and Death Rates for an Unusual Event, by Sex and Socioeconomic Status

Socioeconomic Status
Sex Measure High Middle Low Total

Males Persons at risk 179 173 499 851

Deaths 120 148 441 709
Death rate (%) 67.0% 85.5% 88.4% 83.3%

Females Persons at risk 143 107 212 462

Deaths 9 13 132 154
Death rate (%) 6.3% 12.6% 62.3% 33.3%

Both sexes Persons at risk 322 280 711 1313

Deaths 129 161 573 863
Death rate (%) 40.1% 57.5% 80.6% 65.7%

Table 1.6 Deaths and Death Rates for an Unusual Event, by Age and
Socioeconomic Status

Socioeconomic Status
Age Group Measure High / Middle Low Total

Adults Persons at risk 566 664 1230

Deaths 287 545 832
Death rate (%) 50.7% 82.1% 67.6%

Children Persons at risk 36 47 83

Deaths 3 28 31
Death rate (%) 8.3% 59.6% 37.3%

All Ages Persons at risk 602 711 1313

Deaths 290 573 863
Death rate (%) 48.2% 80.6% 65.7%

pls check pg 13 -

14

Check your answers on page 1-82

Introduction to Epidemiology
Page 1-45
 Exercise 1.7
Classify each of the following studies as:

A. Experimental
B. Observational cohort
C. Observational case-control
D. Observational cross-sectional
E. Not an analytical or epidemiologic study

d
__________ 1. Representative sample of residents were telephoned and asked how much
they exercise each week and whether they currently have (have ever been
diagnosed with) heart disease.

:
__________ 2. Occurrence of cancer was identified between April 1991 and July 2002 for
50,000 troops who served in the first Gulf War (ended April 1991) and
50,000 troops who served elsewhere during the same period.

__________ 3. Persons diagnosed with new-onset Lyme disease were asked how often
they walk through woods, use insect repellant, wear short sleeves and
pants, etc. Twice as many patients without Lyme disease from the same
physician’s practice were asked the same questions, and the responses in
the two groups were compared.
a
__________ 4. Subjects were children enrolled in a health maintenance organization. At
2 months, each child was randomly given one of two types of a new
vaccine against rotavirus infection. Parents were called by a nurse two
weeks later and asked whether the children had experienced any of a list
of side-effects.

Check your answers on page 1-83

Introduction to Epidemiology
Page 1-51
 Exercise 1.8
Read the Anthrax Fact Sheet on the following 2 pages, then answer the
questions below.

1. Describe its causation in terms of agent, host, and environment.

a. Agent:

b. Host:

c. Environment:

2. For each of the following risk factors and health outcomes, identify whether they are
necessary causes, sufficient causes, or component causes.

Risk Factor Health Outcome

____________
Component
cause
a. Hypertension Stroke
____________
necessary cause b. Treponema pallidum Syphilis
____________
component
cause c. Type A personality Heart disease
____________
sufficient
cause d. Skin contact with a strong acid Burn

Check your answers on page 1-83

Introduction to Epidemiology
Page 1-56
 Exercise 1.9
Information about dengue fever is provided on the following pages. After
studying this information, outline the chain of infection by identifying the
reservoir(s), portal(s) of exit, mode(s) of transmission, portal(s) of entry,
and factors in host susceptibility.

Reservoirs:

Portals of exit:

Modes of transmission:

Portals of entry:

Factors in host susceptibility:

:
answers a

Check your answers on page 1-84

Introduction to Epidemiology
Page 1-69
 Exercise 1.10
For each of the following situations, identify whether it reflects:

A. Sporadic disease
B. Endemic disease
C. Hyperendemic disease
D. Pandemic disease
E. Epidemic disease

___________
e 1. 22 cases of legionellosis occurred within 3 weeks among residents of a
particular neighborhood (usually 0 or 1 per year)

__________ 2. Average annual incidence was 364 cases of pulmonary

:
tuberculosis per 100,000 population in one area, compared with national
average of 134 cases per 100,000 population

__________ 3. Over 20 million people worldwide died from influenza in 1918-1919

q
__________ 4. Single case of histoplasmosis was diagnosed in a community
b
__________ 5. About 60 cases of gonorrhea are usually reported in this region per week,
slightly less than the national average

Check your answers on page 1-84

Introduction to Epidemiology
Page 1-74
 Exercise 1.11
For each of the following situations, identify the type of epidemic spread
with which it is most consistent.

A. Point source
B. Intermittent or continuous common source
C. Propagated

c
__________ 1. 21 cases of shigellosis among children and workers at a day
care center over a period of 6 weeks, no external source identified
incubation period for shigellosis is usually 1-3 days)
b
_________ 2. 36 cases of giardiasis over 6 weeks traced to occasional use of a
supplementary reservoir (incubation period for giardiasis 3-25 days or
more, usually 7-10 days)
a
__________ 3. 43 cases of norovirus infection over 2 days traced to the ice machine on a
cruise ship (incubation period for norovirus is usually 24-48 hours)

Check your answers on page 1-84

Introduction to Epidemiology
Page 1-79
 Exercise Answers

Exercise 1.1
1. B
2. B
3. A
4. A
5. C
6. A

Exercise 1.2
1. Having identified a cluster of cases never before seen in the area, public health officials must
seek additional information to assess the community’s health. Is the cluster limited to persons
who have just returned from traveling where West Nile virus infection is common, or was the
infection acquired locally, indicating that the community is truly at risk? Officials could
check whether hospitals have seen more patients than usual for encephalitis. If so, officials
could document when the increase in cases began, where the patients live or work or travel,
and personal characteristics such as age. Mosquito traps could be placed to catch mosquitoes
and test for presence of the West Nile virus. If warranted, officials could conduct a
serosurvey of the community to document the extent of infection. Results of these efforts
would help officials assess the community’s burden of disease and risk of infection.
2. West Nile virus infection is spread by mosquitoes. Persons who spend time outdoors,
particularly at times such as dusk when mosquitoes may be most active, can make personal
decisions to reduce their own risk or not. Knowing that the risk is present but may be small,
an avid gardener might or might not decide to curtail the time spent gardening in the evening,
or use insect repellent containing DEET, or wear long pants and long-sleeve shirts even
though it is August, or empty the bird bath where mosquitoes breed.
3. What proportion of persons infected with West Nile virus actually develops encephalitis? Do
some infected people have milder symptoms or no symptoms at all? Investigators could
conduct a serosurvey to assess infection, and ask about symptoms and illness. In addition,
what becomes of the persons who did develop encephalitis? What proportion survived? Did
they recover completely or did some have continuing difficulties?
4. Although the cause and mode of transmission were known (West Nile virus and mosquitoes,
respectively), public health officials asked many questions regarding how the virus was
introduced (mosquito on an airplane? wayward bird? bioterrorism?), whether the virus had a
reservoir in the area (e.g., birds), what types of mosquitoes could transmit the virus, what
were the host risk factors for infection or encephalitis, etc.

Introduction to Epidemiology
Page 1-81
Exercise 1.3
1. A
2. E
3. F
4. B
5. D
6. C

Exercise 1.4
1. Confirmed
2. Probable
3. Probable
4. Probable
5. Possible

Exercise 1.5
1. Third criterion may be limiting because patient may not be aware of close contact
2. Probably reasonable
3. Criteria do not require sophisticated evaluation or testing, so can be used anywhere in the
world
4. Too broad. Most persons with cough and fever returning from Toronto, China, etc., are more
likely to have upper respiratory infections than SARS.

Exercise 1.6
The following tables can be created from the data in Tables 1.5 and 1.6:

Table A. Deaths and Death Rates for an Unusual Event, By Sex and Socioeconomic Status

Female Male
High Middle Low High Middle Low

Persons at risk 143 107 212 179 173 499

Survivors 134 94 80 59 25 58
Deaths 9 13 132 120 148 441
Death rate (%) 6.3 12.1 62.3 67.0 85.5 88.4

Table B. Deaths and Death Rates for an Unusual Event, By Sex

Female Male Total

Persons at risk 462 851 1,313

Survivors 308 142 450
Deaths 154 709 863
Death rate (%) 33.3 83.3 65.7

Introduction to Epidemiology
Page 1-82
Table C. Deaths and Death Rates for an Unusual Event, By Age Group

Child Adult Total

Persons at risk 83 1,230 1,313

Survivors 52 398 450
Deaths 31 832 863
Death rate (%) 37.3 67.6 65.7

By reviewing the data in these tables, you can see that men (see Table B) and adults (see Table
C) were more likely to die than were women and children. Death rates for both women and men
declined as socioeconomic status increased (see Table A), but the men in even the highest
socioeconomic class were more likely to die than the women in the lowest socioeconomic class.
These data, which are consistent with the phrase “Women and children first,” represent the
mortality experience of passengers on the Titanic.

Data Sources: Passengers on the Titanic [Internet]. StatSci.org; [updated 2002 Dec 29; cited 2005 April]. Available from
http:/ /www.statsci.org/data/general/titanic.html.
Victims of the Titanic Disaster [Internet]. Encyclopedia Titanica; [cited 2005 April]. Available from http:/ /www.encyclopedia-
titanica.org.

Note:the precise number of passengers, deaths, and class of service are disputed. The Encyclopedia Titanica website includes
numerous discussions of these disputed numbers.

Exercise 1.7
1. D
2. B
3. C
4. A

Exercise 1.8
1.
a. Agent - Bacillus anthracis, a bacterium that can survive for years in spore form, is a
necessary cause.
b. Host - People are generally susceptible to anthrax. However, infection can be prevented
by vaccination. Cuts or abrasions of the skin may permit entry of the bacteria.
c. Environment - Persons at risk for naturally acquired infection are those who are likely to
be exposed to infected animals or contaminated animal products, such as veterinarians,
animal handlers, abattoir workers, and laboratorians. Persons who are potential targets of
bioterrorism are also at increased risk.

2.
a. Component cause
b. Necessary cause
c. Component cause
d. Sufficient cause

Introduction to Epidemiology
Page 1-83
Exercise 1.9
Reservoirs: humans and possibly monkeys
Portals of exit: skin (via mosquito bite)
Modes of transmission: indirect transmission to humans by mosquito vector
Portals of entry: through skin to blood (via mosquito bite)
Factors in host susceptibility: except for survivors of dengue infection who are immune to
subsequent infection from the same serotype, susceptibility is universal

Exercise 1.10
1. E
2. C
3. D
4. A
5. B

Exercise 1.11
1. C
2. B
3. A

Introduction to Epidemiology
Page 1-84
 multiple answers po
pg ;
21 it
talaga check pg
SELF-ASSESSMENT QUIZ
,

with doubt
Now that you have read Lesson 1 and have completed the exercises, you
should be ready to take the self-assessment quiz. This quiz is designed to
help you assess how well you have learned the content of this lesson. You
may refer to the lesson text whenever you are unsure of the answer.

Unless instructed otherwise, choose ALL correct answers for each question.

1. In the definition of epidemiology, “distribution” refers to:

A. Who person
-

B. When time -

C. Where place-

D. Why -
determinants ( How why )
,

2. In the definition of epidemiology, “determinants” generally includes:

A. Agents
B. Causes
C. Control measures
D. Risk factors
E. Sources

3. Epidemiology, as defined in this lesson, would include which of the following activities?
A. Describing the demographic characteristics of persons with acute aflatoxin poisoning in
District A
B. Prescribing an antibiotic to treat a patient with community-acquired methicillin-
resistant Staphylococcus aureus infection
C. Comparing the family history, amount of exercise, and eating habits of those with and
without newly diagnosed diabetes
D. Recommending that a restaurant be closed after implicating it as the source of a
hepatitis A outbreak

4. John Snow’s investigation of cholera is considered a model for epidemiologic field

investigations because it included a:
A. Biologically plausible hypothesis
B. Comparison of a health outcome among exposed and unexposed groups
C. Multivariate statistical model
D. Spot map
E. Recommendation for public health action

5. Public health surveillance includes which of the following activities:

A. Diagnosing whether a case of encephalitis is actually due to West Nile virus infection
B. Soliciting case reports of persons with symptoms compatible with SARS from local
hospitals
C. Creating graphs of the number of dog bites by week and neighborhood
D. Writing a report on trends in seat belt use to share with the state legislature
E. Disseminating educational materials about ways people can reduce their risk of Lyme
disease

Introduction to Epidemiology
Page 1-85
6. The hallmark feature of an analytic epidemiologic study is: (Choose one best answer)
A. Use of an appropriate comparison group
B. Laboratory confirmation of the diagnosis
C. Publication in a peer-reviewed journal
D. Statistical analysis using logistic regression

7. A number of passengers on a cruise ship from Puerto Rico to the Panama Canal have
recently developed a gastrointestinal illness compatible with norovirus (formerly called
Norwalk-like virus). Testing for norovirus is not readily available in any nearby island, and
the test takes several days even where available. Assuming you are the epidemiologist
called on to board the ship and investigate this possible outbreak, your case definition
should include, at a minimum: (Choose one best answer)
A. Clinical criteria, plus specification of time, place, and person
B. Clinical features, plus the exposure(s) you most suspect
C. Suspect cases
D. The nationally agreed standard case definition for disease reporting

8. A specific case definition is one that:

A. Is likely to include only (or mostly) true cases
B. Is considered “loose” or “broad”
C. Will include more cases than a sensitive case definition
D. May exclude mild cases

9. Comparing numbers and rates of illness in a community, rates are preferred for: (Choose
one best answer)
A. Conducting surveillance for communicable diseases
B. Deciding how many doses of immune globulin are needed
C. Estimating subgroups at highest risk
D. Telling physicians which strain of influenza is most prevalent

10. For the cruise ship scenario described in Question 7, how would you display the time
course of the outbreak? (Choose one best answer)
A. Endemic curve
B. Epidemic curve
C. Seasonal trend
D. Secular trend

11. For the cruise ship scenario described in Question 7, if you suspected that the norovirus
may have been transmitted by ice made or served aboard ship, how might you display
“place”?
A. Spot map by assigned dinner seating location
B. Spot map by cabin
C. Shaded map of United States by state of residence
D. Shaded map by whether passenger consumed ship’s ice or not

Introduction to Epidemiology
Page 1-86
12. Which variables might you include in characterizing the outbreak described in Question 7
by person?
A. Age of passenger
B. Detailed food history (what person ate) while aboard ship
C. Status as passenger or crew
D. Symptoms

13.When analyzing surveillance data by age, which of the following age groups is preferred?
(Choose one best answer)
A. 1-year age groups
B. 5-year age groups
C. 10-year age groups
D. Depends on the disease

14. A study in which children are randomly assigned to receive either a newly formulated
vaccine or the currently available vaccine, and are followed to monitor for side effects
and effectiveness of each vaccine, is an example of which type of study?
A. Experimental
B. Observational
C. Cohort
D. Case-control
E. Clinical trial

15. The Iowa Women’s Health Study, in which researchers enrolled 41,837 women in 1986 and
collected exposure and lifestyle information to assess the relationship between these
factors and subsequent occurrence of cancer, is an example of which type(s) of study?
A. Experimental
B. Observational
C. Cohort
D. Case-control
E. Clinical trial

16. British investigators conducted a study to compare measles-mumps-rubella (MMR) vaccine

history among 1,294 children with pervasive development disorder (e.g., autism and
Asperger’s syndrome) and 4,469 children without such disorders. (They found no
association.) This is an example of which type(s) of study?
A. Experimental
B. Observational
C. Cohort
D. Case-control
E. Clinical trial

Source: Smeeth L, Cook C, Fombonne E, Heavey L, Rodrigues LC, Smith PG, Hall AJ. MMR vaccination and pervasive developmental
disorders. Lancet 2004;364:963–9.

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17. A cohort study differs from a case-control study in that:
A. Subjects are enrolled or categorized on the basis of their exposure status in a cohort
study but not in a case-control study
B. Subjects are asked about their exposure status in a cohort study but not in a case-
control study
C. Cohort studies require many years to conduct, but case-control studies do not
D. Cohort studies are conducted to investigate chronic diseases, case-control studies are
used for infectious diseases

18. A key feature of a cross-sectional study is that:

A. It usually provides information on prevalence rather than incidence
B. It is limited to health exposures and behaviors rather than health outcomes
C. It is more useful for descriptive epidemiology than it is for analytic epidemiology
D. It is synonymous with survey

19. The epidemiologic triad of disease causation refers to: (Choose one best answer)
A. Agent, host, environment
B. Time, place, person
C. Source, mode of transmission, susceptible host
D. John Snow, Robert Koch, Kenneth Rothman

20. For each of the following, identify the appropriate letter from the time line in Figure 1.27
representing the natural history of disease.
_____
C Onset of symptoms
_____
D Usual time of diagnosis
_____
A Exposure

Figure 1.27 Natural History of Disease Timeline

21. A reservoir of an infectious agent can be:

A. An asymptomatic human
B. A symptomatic human
C. An animal
D. The environment

Introduction to Epidemiology
Page 1-88
22. Indirect transmission includes which of the following?
A. Droplet spread
B. Mosquito-borne
C. Foodborne
D. Doorknobs or toilet seats

23. Disease control measures are generally directed at which of the following?
A. Eliminating the reservoir
B. Eliminating the vector
C. Eliminating the host
D. Interrupting mode of transmission
E. Reducing host susceptibility

24. Which term best describes the pattern of occurrence of the three diseases noted below in
a single area?
A. Endemic
B. Outbreak
C. Pandemic
D. Sporadic
A
____ Disease 1: usually 40–50 cases per week; last week, 48 cases
____
D Disease 2: fewer than 10 cases per year; last week, 1 case
____
B Disease 3: usually no more than 2–4 cases per week; last week, 13 cases

25. A propagated epidemic is usually the result of what type of exposure?

A. Point source
B. Continuous common source
C. Intermittent common source
D. Person-to-person

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Answers to Self-Assessment Quiz
1. A, B, C. In the definition of epidemiology, “distribution” refers to descriptive
epidemiology, while “determinants” refers to analytic epidemiology. So “distribution”
covers time (when), place (where), and person (who), whereas “determinants” covers
causes, risk factors, modes of transmission (why and how).

2. A, B, D, E. In the definition of epidemiology, “determinants” generally includes the causes

(including agents), risk factors (including exposure to sources), and modes of transmission,
but does not include the resulting public health action.

3. A, C, D. Epidemiology includes assessment of the distribution (including describing

demographic characteristics of an affected population), determinants (including a study of
possible risk factors), and the application to control health problems (such as closing a
restaurant). It does not generally include the actual treatment of individuals, which is the
responsibility of health-care providers.

4. A, B, D, E. John Snow’s investigation of cholera is considered a model for epidemiologic

field investigations because it included a biologically plausible (but not popular at the
time) hypothesis that cholera was water-borne, a spot map, a comparison of a health
outcome (death) among exposed and unexposed groups, and a recommendation for public
health action. Snow’s elegant work predated multivariate analysis by 100 years.

5. B, C, D. Public health surveillance includes collection (B), analysis (C), and dissemination
(D) of public health information to help guide public health decision making and action,
but it does not include individual clinical diagnosis, nor does it include the actual public
health actions that are developed based on the information.

6. A. The hallmark feature of an analytic epidemiologic study is use of an appropriate

comparison group.

7. A. A case definition for a field investigation should include clinical criteria, plus
specification of time, place, and person. The case definition should be independent of the
exposure you wish to evaluate. Depending on the availability of laboratory confirmation,
certainty of diagnosis, and other factors, a case definition may or may not be developed
for suspect cases. The nationally agreed standard case definition for disease reporting is
usually quite specific, and usually does not include suspect or possible cases.

8. A, D. A specific or tight case definition is one that is likely to include only (or mostly) true
cases, but at the expense of excluding milder or atypical cases.

9. C. Rates assess risk. Numbers are generally preferred for identifying individual cases and
for resource planning.

10. B. An epidemic curve, with date or time of onset on its x-axis and number of cases on the
y-axis, is the classic graph for displaying the time course of an epidemic.

11. A, B, C. “Place” includes location of actual or suspected exposure as well as location of

residence, work, school, and the like.

Introduction to Epidemiology
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12. A, C. “Person” refers to demographic characteristics. It generally does not include clinical
features characteristics or exposures.

13. D. Epidemiologists tailor descriptive epidemiology to best describe the data they have.
Because different diseases have different age distributions, epidemiologists use different
age breakdowns appropriate for the disease of interest.

14. A, E. A study in which subjects are randomized into two intervention groups and
monitored to identify health outcomes is a clinical trial, which is type of experimental
study. It is not a cohort study, because that term is limited to observational studies.

15. B, C. A study that assesses (but does not dictate) exposure and follows to document
subsequent occurrence of disease is an observational cohort study.

16. B, D. A study in which subjects are enrolled on the basis of having or not having a health
outcome is an observational case-control study.
Source: Smeeth L, Cook C, Fombonne E, Heavey L, Rodrigues LC, Smith PG, Hall AJ. MMR vaccination and pervasive
developmental disorders. Lancet 2004;364:963–9.

17. A. The key difference between a cohort and case-control study is that, in a cohort study,
subjects are enrolled on the basis of their exposure, whereas in a case-control study
subjects are enrolled on the basis of whether they have the disease of interest or not.
Both types of studies assess exposure and disease status. While some cohort studies have
been conducted over several years, others, particularly those that are outbreak-related,
have been conducted in days. Either type of study can be used to study a wide array of
health problems, including infectious and non-infectious.

18. A, C, D. A cross-sectional study or survey provides a snapshot of the health of a

population, so it assesses prevalence rather than incidence. As a result, it is not as useful
as a cohort or case-control study for analytic epidemiology. However, a cross-sectional
study can easily measure prevalence of exposures and outcomes.

19. A. The epidemiologic triad of disease causation refers to agent-host-environment.

20. C Onset of symptoms

D Usual time of diagnosis
A Exposure

21. A, B, C, D. A reservoir of an infectious agent is the habitat in which an agent normally

lives, grows, and multiplies, which may include humans, animals, and the environment.

22. B, C, D. Indirect transmission refers to the transmission of an infectious agent by

suspended airborne particles, inanimate objects (vehicles, food, water) or living
intermediaries (vectors such as mosquitoes). Droplet spread is generally considered short-
distance direct transmission.

23. A, B, D, E. Disease control measures are generally directed at eliminating the reservoir or
vector, interrupting transmission, or protecting (but not eliminating!) the host.

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24. A Disease 1: usually 40–50 cases per week; last week, 48 cases
D Disease 2: fewer than 10 cases per year; last week, 1 case
B Disease 3: usually no more than 2–4 cases per week; last week, 13 cases

25. D. A propagated epidemic is one in which infection spreads from person to person.

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