Problem Based Interactive Learning in Epidemiology

I am starting an interactive Problem based Scenario for understanding the fundamental concepts of Epidemiology. All of you in 1st, 2nd and 3rd Semester are required to answer individually to the questions and when you will answer those questions, I will further build up the scenario and ask further questions, and the cycle will go on, to make you understand the concepts. Participation is a MUST.

A sickness of unknown type, which appears as outbreaks, sometimes affecting whole communities, is spreading across a large part of continental Europe. Years later it will emerge in the USA. It will be shown to be present in many countries, though it may remain unrecognized in normal medical practice, for it may occur as solitary cases or in small numbers and not outbreaks. Sick people have a wide range of symptoms and signs on examination. Their many symptoms include simply feeling unwell,with loss of appetite and abdominal pain, disturbances of the gastrointestinal tract including diarrhoea, a skin rash on parts of the body exposed to the sun, and mental disturbances.
It leads to progressive physical and mental deterioration. People who contract the sickness are likely to die, with the mortality rate as high as 60 per cent in some outbreaks. If a sufferer recovers the sickness can recur. The sickness clusters in families, and it affects the poor living in rural areas more than any other group. Sharecropping and growing of corn are common in areas where the disease occurs. The problem is greatest in spring, though the early symptoms occur in winter. The sickness is common in prisoners and patients in asylums.
It does not affect staff in the institutions. Physicians cannot agree on the cause of the sickness and the many ‘cures’ tried by physicians and quacks give variable results.

Questions
1. Can you form a definition of this sickness X? If not, how would physicians make a diagnosis? How could the number of cases of the sickness be counted?

2. If you can define it how would you do it? What would be the components of your definition?

Dear Sir ,

The no.of cases can be counted through the measuring of disease .
measuring of disease can be done through the following tools.

1.Ratio
2.proportion
3.incidence
4.prevalence rate.

the no.of cases can be counted through the following formula

Rate = the no.of event in a specific period / population at risk in aspecific period Multiply by K

Cummulative incidence = No.of new cases of disease / population at risk at a point in time

Incidence rate or density = No.of new caeses /person-time denominator at apoint in time

Thanks

Dr.Zahid

Dear Dr Salarzai, kindly read the questions once again before answering. First read the whole scenario carefully. What definition of the disease in the given problem would you make. Think very very hard. Put a lots of pressure on your brain. Test it at its extreme so that you are about to get a headache, only then try to answer

Hypothyroid MPH Students, you are supposed to answer this question

I am once again warning the Hypothyroids that they have to answer this question, otherwise those who fail to answer this question by Friday will not be allowed to sit in my class on that Day. This is a FINAL WARNING.

Dear sir,

Can we make a humble try ? If you allow.

If not on the forum, I would like to express myself on this very interesting question to your e-mail. I am not confident if I'll be correct.

Sure, everyone is welcome but I was referring to the super idiots of 1st, 2nd and 3rd Semester (Specially 2nd and 3rd Semester), as this class mainly consists of Mega Mega Idiots from all over the world

Thank you sir.

My answer may be a pure blunder or may comprise of blunders. Please accept my advance apologies.

Your comments will be of utmost importance and a source or learning.

Here we go:

Important / Notable things in the question"

· Sickness of unknown type

o Appears a outbreak in communities and spreading across the continental Europe and will emerge to USA.

o May occur as solitary cases or in small number

o May remain unrecognized in normal medical practice

· Wide range of symptoms

o Malaise

o Loss of appetite

o Abdominal pain

o GI disturbances

o Diarrhea

o Skin rash on the exposed parts

· 60% with disease likely to die

· Clusters in families

· Mostly affects poor in rural areas

· Sharecropping and corn areas affected

· Recurrence can occur

· Mostly arises Spring with early symptoms in winter

· Common in prisoners and asylums

· Does not affect staff in institutions


Definition (A crude one to be buil upon):

It seems to be a pandemic (syndrome yet) with the following characteristics:

Determinants:

- Agent: not known

- Host: Poor, mostly asylums and prisoners

- Environment: Spring and winter season, crop sharing and corn areas

Distribution:

- Time: Spring / early features in winter

- Place: Rural areas / corn crop areas

- Person:

o Poor socioeconomic group

o Prisoners and asylums at high risk

o Age ? ( any vulnerable group not given in the question)

o The fact that the disease clusters in families may lead us to:

§ Genetic predisposition

§ Highly contagious

How to count the number of cases ?

To count the absolute number of cases may not be possible but forming a good and functional “Surveillance system” may make it possible to have a measure of the extent of the disease and some of its characteristics. After identifying the health facilities to be included in the surveillance network, active and passive surveillance can be initiated according to the priority after some orientation training of the health staff on case identification and data collection.

What the clinicians may do?

Urgent collaboration between the clinicians and Public health doctors is needed in this situation (mortality 60%) for:


· Determining the agent / causation which may require

o Certain serological investigations

o Invasive procedures (colonoscopy, sigmoidoscopy, endoscopy etc.)

o Gut biopsy

· Mode of transmission (if contagious and not familial).

Hmmmmm...... interesting. I will wait for a few more responses (if any from the low IQ corpses) and then I will give my feedback. Stay tuned

This is last warning to MPH students. All those who havent answered will be banned for next class. Choice is theirs,.... ~*%#@%

Good. I will wait for another 24 hours and then I will guide answer to this part of the question and further build up this hypothetical scenario

Etiology-------unknwon origion
Pndemic---appear as outbreak,small number and also solitary
Symptoms
feeling unwell
loss of aapetite
abdomina pain
diarrhoea
skin rash(on parts of the body exposed to sun)
mental disturbancesmortality rate 60%
Knoing determinants
Agent---Unknown
Host---- poor rural people.
Enviroment-problem in spring and early early symptoms occur in winter.Sharecropping and growing of corn are common in thease areas.common in prisoners and patients of asylums.
Agent----?
combind efforts of physician and public health officer
Serological investigation
gut biopsy

R/Sir,

Trying my best to respond accordingly, but appologies in advance should be accepted in wrong or blunders as this is my first assignment in the subject cited.

Definition of the Disease:
An idiopathic infectious disease affecting multi systems, occuring sporadically but have the tendency of both epidemic and as well as pandemic.

Background/Symptoms:
1. Feeling unwell
2. Loss of apetite and Abdominal Pain
3. Disturbance of gestrointestinal tract
4. Diarrhea
5. Skin rashes to sun exposed parts
6. Mental disturbance
7. Occure in outbreak
8. Mortality rate high
9. Re-occure after recovering of the suffer
10. Seems seasonal orientation

How the Disease will be Diagnosis by the Physician/Public Health Expert:


We have to keep in mind the following three constant factors evolving in the whole process, that is
a). Time
b). Place
c). Person
Firstly we have to see the mode of a disease that vary over time across the population.
Secondly that how the place in which a person lives affect the disease pattern.
Thirdly how the person characteristics in population affect the disease pattern.


Sorry Sir, unable to respond the question concerning about the number of cases of the sickness be counted.


Ashiq Zaman Khattak
1st Semester MMPH

Dear sir,
I read the scenario several times before answering the question and i understood that one should clear its concept about the epidemiology to solve this problem. The things which i understood in this question are following.As a epidiomologist i will consider the following things to solve this question.

1:What is the problem?
Problem includes signs and symptons of the disease.the symptons of the given problem are
1:Feeling unwell
2:Loss of appetite
3:Abdominal pain
4:Disturbance of the gastrointestinal tract
5:Skin rush (on the parts of the body which are exposed to the sun)
6:Mental disturbance

2:Who are sufferring from the problem?
1:Age(not given)
2:Sex(not given
3:Group of the society(which group)(poor people living in rural areas)
4:Occupation(not given)

3:Where?
1:which area(rural areas)
2:Geographical area(Europe and USA)
4:place of incidence

4:When?
1:which season?(SYMPTONS occuring in WINTER and problem occuring in spring)
2:which year?(not given)
3:which month?(not given)

5:time needed forthe disease to spread
(either this disease spread in a month or in weak or in days)

6:how did it occur?
1:Source of disease
2:transmitters of disease
3:Risk factor

7:Why the disease spread?

8:In which people the disease is found
people in groups(prisoners and asylum)

9:counting the number of cases
1:number of the cases can be counted by following method
no of cases in the area in specific period divided by the total population of that area

AS a physician the steps i would take
1:labrotrical and clinical diagnosis.


According to me the problem can be solved in the above mentioned way but if my method is wrong i will study again the whole concept of epidemiology.

Thanks
Dr.Nazifa.

Sir

It is a vey interesting excercise which will initiate and stimulate the neurons. Extend the deadline to 17th of March 2009. Let us think and formulate something very relevant & logical.

A scientific defintion is a must if the case has to be defined, bcoz otherwise many diseases which will not be this unknown disease will be misclassified as this disease, while many actual cases of this disease may be wrongly diagnozed as something else.

Ans1: A exact definition is not possible at this stage with limited info. Physicians diagnosis at this stage will either be an overstatement or understatment of the real problem, as either some false cases would be classified as this disease or some real cases may be not diagnosed.

Ans 2: The diseases is unknown but from the limited info, a working definition can be crafted which is an illness diagnosed by physician, occuring in clusters and which includes loss of apetite, gastro disturbances, diarhea, mental problems and skin rash and for which no other clear diagnosis can be found.

Based on this definition, we can record all possible cases of this unknown disease

 sir being a dentist its very tough  for meto give to the point answer.any way i am trying my level best .as for as i think this disease is AIDS.a patient with such symptoms 
will be investigated as.....
1- blood cp
2- pCR for HIV RNA
3-CD 4 COUNT
4- Urea critinine
5- Xray chest
6-BSR,ANTI HIV (ELIZA)
I AM trying to think more about this disorder and i hope i will get good answer. thanks sorry for any wrong statement.

dear sir
from the case presented here i am unable to define it scientifically,
but i think that we should study about the determinents, distribution and its dynamics.
regarding to this case as it is appear in continental europe so intially it look like epidemic but later on it spread to USA so demonstrating it going to pandemic.
for diagnose the important component is there and these are the following the population is at risk or affected they are poor, they are livig in rural areas. so we must invetigate about the causative agent, the population which are at risk ,the specific locality, epidemiological triangle i.e: host , agent and enviroment.
as this disease affect the poor peoples so it is confirmed that their is some problem in the internal enviroment, and external enviroment i.e: poverty is alaso a factor for that.intially it follow single unit spreading and later it become propagated.
as much i understand from the above scenario we must establish a diagnose by identifying the specific causative agent and the time period as it is occur in spring ,
and we must think about the mode of transmission and succeptible populations.
so in my opinion if we follow this scheme then we will be able to identify the above case.

Dear Sir,

With due respect, despite I was so busy last week I tried to find the exact definition for this disease, but at this moment it will be a little difficult for us.

However my impression about this scenario is as below:

1 – Definition:

It is an infectious disease (RMSF) caused by Rickettsia Rickettsii, which is transmitted to human by the bite of ticks, including the wood tick, Dermacentor andersoni, in the Western United States and by the bite of the dog tick, Dermancentor variabilis in the eastern United States.



2- Diagnosis:

Serial serological examination by indirect fluorescent antibody (IFA) confirm the diagnosis retrospectively.



3 – Counting of Cases:

First a strong surveillance system is needed. And by rate, incidence and prevalence we can counted the cases.





Dr. Fidaullah “Naseeri”

Master Trainer

HealthNet TPO

Jalalabad, Afhganistan

Now the actual answer to this is as follow. Please read this carefully, at least 100 times, and try to clear the concepts, and understand how the professionals answer such question.

Now let me call this unknown Sickness X. The scenario illustrates why epidemiology requires clinical collaboration. Since the cause is unknown the disease must be defined on the clinical picture, or laboratory tests. If a definition cannot be agreed or the definition is inaccurate, cases cannot be diagnosed and epidemiology is paralysed, or led to error. The first question for the epidemiologist, in any investigation, is the nature and validity of the definition of the disease or other problem under investigation. Clinicians need to study cases and agree on a definition which will permit the classification of sick people into one of two groups: probably suffering from the disease or probably not. Diagnoses are no more than statements of probability, and their accuracy will depend on the clarity of the definition of the disease. A definition of sickness X which accepted only patients with a rash as cases would miss those without a rash. To accept cases of disease without a rash means that more people suffering from other disorders will be wrongly diagnosed with sickness X.
Pragmatic choices will need to be made. For the purposes of scientific investigation, a definition which includes people with a high probability of disease is likely to be better than one which includes many people without. For public health action the same definition may be inadequate, for it underestimates the size of the problem and misses the people most likely to benefit: those with early symptoms.

A possible definition would be that a case of sickness X is, for the purpose of epidemiological research,

1) an illness diagnosed by a physician;
2) one of a cluster or outbreak of cases;
one that occurs in an ill person who has at least two out of these three problems:
3) gastrointestinal disturbance
4) skin rash
5) mental disturbance
6) one with no other clear diagnosis.

Using this pragmatic definition physicians can be asked to inform the researchers of the occurrence of cases, which can be counted and studied. The effect of error in the definition on the estimated frequency of the disease may be huge and comparison of different populations is likely to be misleading but an approximate definition is still essential.
Consider, for comparison, the definition used by some famous Public Health Experts in their investigation of the 1976 Legionnaires’ disease outbreak in Philadelphia in USA: a case had a fever of at least 102 degrees and a cough, or a fever allied to chest X-ray evidence of pneumonia, plus some association with the Legion convention. The definition was designed to separate those who were probably linked to the outbreak from those who were not. Later, when the importance of the Bellevue Hotel in Philadelphia as the source of exposure became clearer, the definition was revised to include only people who were American Legion conventioneers or who had entered the Bellevue Stratford Hotel after 1 July 1976. The change in definition caused confusion in the minds of the public and the media, and changed the numbers of cases involved and dead. Similarly, a change in the definition of AIDS some years ago led to changes in the numbers of cases. Changes in case definition are common, reflecting the fact that diagnosis is often pragmatic.

Thanks, sir.

I have been waiting for your comments which finally came.
Jumping straight to conclusion without having enough and valid evidences and grounds is not wise, as your explaination suggests.

Now further building on the same scenario and in light of the above discussion,

1. What thoughts come into your mind about the nature of the sickness? What kind of sickness/disease is it?
2. What kind of sickness/disease is it not?
3. What sort of factors could cause a sickness such as this?

Come on..... Hypos..... Wake Up. Answer if you dont want to get banned in my classes

Niamatullah
Ist Semester
Reply of the case study

Its a senario for investigating the epidemic in the area.
we will have to answer the following question
1. Whats has happened?
Not feeling well
Loss of Appitte
Disturbace of GIT Tract
Mental Disturbance
Skin Rash on expose part
2. Who?
Poor Community
People living in group community(Prisnors and Asylum)
3. Where?
Rural Area having sharecropping
4. When?
Early Spring
Winter
5. Why?
we will have to answered this question


Regards,

Niamatullah
Ist Semester

solution!

Risk{incidence}of desease= A/A+B
in exposed group
= 435/435+20165
Risk{incidence}of desease
in exposed group =0.0211


Risk{incidence}of disease= c/c+d
in nonexposed group
= 10/10+14640
= 0.00068


relative risk =a/a+b / c/c+d
= 0.0211 / 0.00068
[u][u][u][u][u][u][u][u][u][u][u][/u][/u][/u][/u][/u][/u][/u][/u][/u][/u][/u]
Relative risk = 31.029

Good to see at least something (Although even is its totally wrong) from our little prince Mohammad Adnan

I wonder where did these values come from ? Or I didn't see them ! ...

I am also wondering to which questions these answers belong to...... Can someone do research on Mohammad Adnan....I guess that will certainly reveal interesting facts, still unknown to us

But Mr Adnan Knows it very well.
Once a profeesor was wearing socks of two diffrent Colours, Students asked him with surprise.
Sir! Your two socks are of two different colours,The absent minded professor was least bothered about it and repllied satisfactorily.
O' Yes I know I know, Exactly an other such pair of socks were also lying in my home.

May be Adnan has another such informations and data in his home too.

I guess he is a Post Doctoral Research Fellow, a super Genuis

Last Chance once again for sleeping Hypos. Otherwise the way Mehnaz and Usman have been banned the rest of the bunch will also be banned. So hurry up!!!!!!! Time is short

Sir,
the condition presented here is little bit complicated.based on clinical investigation and lab test regarding the disease and the time at which it appear from the period it looks like seasonel disease, the various factors which contribute to the disease like poor peoples, corn crops so it seems there is certain vector is responsible for the spreading of disease.
so collecting the data which is already documented and by reviewing the data and further investigational research based on signs and symptoms and by catogorzing according to various abnormal or disease condition then we will be able to properly diagnose it and define.

Dear Sir,

According to he given senior there is a high chance that it is a familial disease or a communicable disease.

There is a less chance that it is a non-communicable disease.

There could be many factors involved like clusters in families, poor living in rural areas cropping and growing of corn, a specific season and may be the poor hygienic condition as well,



Kind Regards,

Sohail Anjum

sir adnan is not taking interest in study bcoz he says that sir nayyar ne usyy prince bnaayaa hey class kaaaa. and classs me 3 log aiseyy hothey hey jo sab kuch kar sakthy hey but cant study .... ye unkii shaaaan k khilaaaf hey.. one is king of class , other is queen malkkaa aaliaaaa. and third one is prince adnan. but noroz and zia rehman are unhappy with sir as they consider themself as prince of abasyn uni....

Dr Nayyar Says that Such Persons are not Princes,But you Should Call Them "La La Gan"

If you just add two of the first 4 alphabets of English Language before the world Lalagan, then I guess something describes the phenomenon very adequately. I hope you got it

Oooffff!
I got your intended Meaning, You mean to prefix Lalagan with the,,,,,One first letter from DOCTOR, AND.......first letter from Abasyn.
Aap bhi Barray SharerHain Sir.

i think my mind is sharpeneing up with this interactive discussion.....

But your mouth is doing this more than your mind. If you want to confirm my comment then look at your avatar.

Hehehehe