Polio Epidemiology Case Study Assignment Paper

Polio Epidemiology Case Study Assignment Paper

Please read the following case and answer the associated questions.

The following case study was adapted from the CDC Epidemiology Program Office, Case Studies in Applied Epidemiology, No. 891-903.

It is the early 1990s. The World Health Organization is planning a program for the global eradication of polio by the year 2000. Likura, a fictitious nation south-central Africa, may become one of the countries selected to test the effectiveness of WHOs polio eradication strategies. Unfortunately, little is known about polio in Likura. The Minister of Health therefore assigned the task of assessing the polio situation to a Ministry worker who has recently returned from an epidemiology course in Atlanta, and who is about to become the District Health Officer in the Ababo District. The Ababo District is a relatively poor rural district with a single hospital and several health centers. The Ababo District has attempted to conduct surveillance on polio cases and deaths over the past five years. The hospital, health centers, and all health workers are supposed to report such cases to the District Health Officer. Polio Epidemiology Case Study Assignment Paper

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Polio Epidemiology Case Study Assignment

One measure of the polio situation in a community is the prevalence of lameness in children, since lameness is a common sequel of polio.

Question 1a: What data might you use (or collect) to determine the incidence of polio in the population?

Question 1b: What data might you use (or collect) to determine the prevalence of polio in the population?

Question 2: What is the difference between active and passive surveillance systems? Is the Ababo surveillance system for polio passive or active?

To gather information on polio prevalence, vaccine coverage, and risk factors for polio, the District Health Officer conducted a survey of children in the district. Lameness was used as a surrogate for polio. The prevalence of lameness by vaccination status is shown in Table 4.

Table Lameness by Vaccination Status among Children 12-23 Months of Age, Ababo District, 1991.

Lame Normal
Polio Vaccine 1 dose 1 242 243
0 doses 9 667 676
10 909 919

Question 3: What is the prevalence of polio (lameness) among vaccinated (1 dose) children?

Question 4: What is the prevalence of polio (lameness) among the unvaccinated children?

Question 5: What is the vaccine coverage (at least one dose) in this population? Polio Epidemiology Case Study Assignment Paper

Question 6: Interpret these data.

The role of epidemiology in infection control and the use of immunisation programs in preventing epidemics

The discipline of epidemiology is broadly defined as “the study of how disease is distributed in populations and the factors that influence or determine this distribution” (Gordis, 2009: 3). Among a range of core epidemiologic functions recognised (CDC, 2012), monitoring and surveillance as well as outbreak investigation are most immediately relevant to identifying and stopping the spread of infectious disease in a population.

Most countries perform routine monitoring and surveillance on a range of infectious diseases of concern to their respective jurisdiction. This allows health authorities to establish a baseline of disease occurrence. Based on this data, it is possible to subsequently discern sudden spikes or divergent trends and patterns in infectious disease incidence. In addition to cause of death which is routinely collected in most countries, many health authorities also maintain a list of notifiable diseases. In the UK, the list of reportable diseases and pathogenic agents maintained by Public Health England includes infectious diseases such as Tuberculosis and Viral Haemorrhagic Fevers, strains of influenza, vaccine-preventable diseases such as Whooping Cough or Measles, and food borne infectious diseases such as gastroenteritis caused by Salmonella or Listeria. (Public Health England, 2010) At the international level, the World Health Organization requires its members to report any “event that may constitute a public health emergency of international concern” (International Health Regulations, 2005). Cases of Smallpox, Poliomyelitis, Severe Acute Respiratory Syndrome (SARS), and new influenza strains are always notifiable. (WHO, undated) These international notification duties allow for the identification of trans-national patterns by collating data from national surveillance systems. Ideally, the system would enable authorities to anticipate and disrupt further cross-national spread by alerting countries to the necessity of tightened control at international borders or even by instituting more severe measures such a bans on air travel from and to affected countries.

As explained in the previous paragraph, data collected routinely over a period of time allows authorities to respond to increases in the incidence of a particular disease by taking measures to contain its spread. This may include an investigation into the origin of the outbreak, for instance the nature of the infectious agent or the vehicle. In other cases, the mode of transmission may need to be clarified. These tasks are part of the outbreak investigation. Several steps can be distinguished in the wake of a concerning notification or the determination of an unusual pattern. These include the use of descriptive epidemiology and analytical epidemiology, the subsequent implementation of control measures, as well as reporting to share experiences and new insights. (Reintjes and Zanuzdana, 2010). Polio Epidemiology Case Study Assignment Paper

In the case of an unusual disease such as the possibility of the recent Ebola outbreak in West Africa to result in isolated cases in Western Europe, it might not be necessary to engage in further epidemiological analysis once the diagnosis has been confirmed. Instead, control measures would be implemented immediately and might include ensuring best practice isolation of the patient and contact tracing to ensure that the infection does not spread further among a fully susceptible local population. Similarly, highly pathogenic diseases such as meningitis that tend to occur in clusters might prompt health authorities to close schools to disrupt the spread. In other types of outbreak investigations identifying the exact disease or exact strain of an infectious agent is the primary epidemiologic task. This might, for instance, be the case if clusters of relatively non-specific symptoms occur and need be confirmed as linked to one another and identified as either a known disease/infectious agent or be described and named. In the same vein, in food-borne infectious diseases, the infectious organism and vehicle of infection may have to be pinpointed by retrospectively tracing food intake, creating comparative tables, and calculating measures of association between possible exposures and outcome (CDC, 2012). Only then can targeted control measures such as pulling product lots from supermarket shelves and issuing a pubic warning be initiated.

Beyond identifying and controlling infectious disease outbreaks, monitoring and surveillance also plays a role in ensuring that primary prevention works as effectively as possible: collecting information on behavioural risk factors in cases such as sexually transmitted diseases can help identify groups that are most at risk and where Public Health interventions may yield the highest benefit. In another example, monitoring immunization coverage and analysing the effectiveness of vaccines over the life course may predict epidemics in the making if coverage is found decreasing or immunity appears to decline in older populations. In addition, the ability to anticipate the potential spread of disease with a reasonable degree of confidence hinges not only on good data collection. Advanced epidemiological methods such as mathematical modelling are equally instrumental in predicting possible outbreak patterns. Flu vaccines, for instance, need to be formulated long before the onset of the annual flu season. Against which particular strains the vaccines are to provide immunity can only be determined from past epidemiological data and modelling. (M’ikanatha et al., 2013) Mathematical models have also played a role in determining the most effective vaccine strategies, including target coverage and ideal ages and target groups, to eliminate the risk of epidemic outbreaks of infectious diseases (Gordis, 2009).

In addition to controlling outbreaks at the source and assuring the key protective strategies such as mass immunisation are effectively carried out, epidemiology is also a tool that allows comprehensive planning for potential epidemics. A scenario described in a research article by Ferguson and colleagues (2006) has as its premise a novel and therefore not immediately vaccine-preventable strain of influenza that has defied initial attempts at control and reached pandemic proportions. The large scale simulation of the theoretical epidemic assesses the potential of several intervention strategies to mitigate morbidity and mortality: international border and travel restrictions, a measure that is often demanded as a kneejerk reaction by policy-makers and citizens is found to have minimal impact, at best delaying spread by a few weeks even if generally adhered to (Ferguson et al., 2006). By contrast, interventions such as household quarantines or school closures that are aimed at interrupting contact between cases, potential carriers, and susceptible individuals are much more effective. . (Ferguson et al., 2006) Time sensitive antiviral treatment and post exposure prophylaxis using the same drugs are additional promising strategies identified. (Ferguson et al., 2006) The latter two potential interventions highlight the role of epidemiological risk assessment in translating anticipated spread of infectious disease into concrete emergency preparedness. For instance, both mass treatment and mass post exposure prophylaxis require advance stockpiling of antivirals. During the last H1N1 epidemic, public and political concern emerged over shortages of the antiviral drug oseltamivir (brand name Tamiflu). (De Clerq, 2006). However, advance stockpiling requires political support and significant resources at a time when governments are trying to reign in health spending and the threat is not immediate. Thus, epidemiologists also need to embrace the role of advocates and advisors that communicate scientific findings and evidence-based projections to decision-makers. Polio Epidemiology Case Study Assignment Paper

That being said, immunisation remains the most effective primary preventive strategies for the prevention and control of epidemics. As one of the most significant factors in the massive decline of morbidity and mortality form infectious disease in the Western world over the last century, vaccination accounts for an almost 100% reduction of morbidity from nine vaccine-preventable diseases such as Polio, Diphtheria, and Measles in the United States between 1900 to 1990. (CDC, 1999) Immunisation programmes are designed to reduce the incidence of particular infectious diseases by decreasing the number of susceptible individuals in a population. This is achieved by administering vaccines which stimulate the body’s immune response. The production of specific antibodies allows the thus primed adaptive immune system to eliminate the full strength pathogen when an individual becomes subsequently exposed to it. The degree of coverage necessary to achieve so called herd immunity- the collective protection of a population even if not every single individual is immune- depends on the of the infectivity and pathogenicity of the respective infectious agent. (Nelson, 2014) Infectivity, in communicable diseases, measures the percentage of infections out of all individuals exposed, whereas pathogenicity is the percentage of infected individuals that progress to clinical disease. (Nelson, 2014). Sub-clinical or inapparent infections are important to take into account because, even though they show no signs and symptoms of disease, people may still be carriers capable of infecting others. Polio is an example of an infectious disease where most infections are inapparent, but individuals are infectious. (Nelson, 2014).

Gauging infectivity is crucial to estimating the level of coverage needed to reach community immunity. The so called basic reproductive rate is a numerical measure of the average number of secondary infections attributable to one single source of disease, e.g. one infected individual. The rate is calculated by taking into account the average number of contacts a case makes, the likelihood of transmission at each contact point, and the duration of infectiousness. (Kretzschmar and Wallinga, 2010). The higher the reproductive rate, i.e. the theoretical number of secondary cases, the higher the percentage of the population that needs to be immunised in order to prevent or interrupt an outbreak of epidemic proportions. For instance, smallpox, which was successfully eradicated in 1980 (World Health Organization, 2010), is estimated to have a basic reproduction number of around 5, requiring a coverage of only 80% of the population to achieve herd immunity. By contrast, the estimated reproduction number for Measles is around 20 and it is believed that immunisation coverage has to reach at least 96% for population immunity to be ensured. (Kretzschmar and Wallinga, 2010). Once the herd immunity threshold is reached, the remaining susceptible individuals are indirectly protected by the immunised majority around them: in theory, no pathogen should be able to reach them because nobody else is infected or an asymptomatic carrier. Even if the unlikely event of an infection among the unvaccinated eventuated, the chain of transmission should be immediately interrupted thanks to the immunised status of all potential secondary cases. Vaccinating primary contacts of isolated cases is also an important containment strategy where a cluster of non-immune individuals was exposed to an infected individual. Such scenarios may apply, for example, where groups of vaccine objectors or marginalized groups not caught by the regular immunisation drive are affected or an imported disease meets a generally susceptible population. Polio Epidemiology Case Study Assignment Paper

However, epidemic prevention does not stop with having reached vaccination targets. Instead, constant monitoring of current coverage is required and adaptations of the immunisation strategy may be needed to ensure that epidemics are reliably prevented. Recent trends underscore the enduring challenge of permanently keeping at bay even diseases that are officially considered eradicated or near eradication: in the United Kingdom, a marked spike in the number of confirmed measles cases has been observed in the last decade, with an increase from under 200 cases in 2001 to just over 2,000 cases in 2012. (Oxford Vaccine Group, undated) The underlying cause is evident from a comparison of case numbers with data from vaccine coverage monitoring: indeed, the number of children receiving the combination Measles vaccine decreased in the 2000s roughly in parallel with the increase in Measles incidence. (Oxford Vaccine Group, undated) Other countries have seen similar trends and have responded with measures intended to increase vaccine uptake: for instance, in Australia, the government recently decided to enact measures that would withhold child benefit payments to parents who refuse to have their children vaccinated. (Lusted and Greene, 2015)

In conclusion, epidemiology, and in particular routine monitoring and surveillance, is a potent tool that enables health authorities to anticipate, detect, and contain the spread of infectious disease. Over the last century, immunisation has proven itself as one of the key interventions to curb infectious disease morbidity and mortality. However, with vaccine-preventable diseases again on the rise in UK and other industrialised countries, epidemiologic monitoring of vaccine coverage and disease incidence remains critically important. Where vaccines are not available or vaccine-induced immunity is short-lived, an effective system to detect cases and contain outbreaks is even more instrumental to the effort of preventing infectious disease epidemics.

Bibliography

Centers for Disease Control and Prevention (CDC) (2012) Principles of Epidemiology in Public Health Practice, 2nd edition, Atlanta, GA: US Department of Health and Human Services.

Centers for Disease Control and Prevention (CDC) (1999) ‘Achievements in Public Health, 1900-1999 Impact of Vaccines Universally Recommended for Children — United States, 1990-1998’, MMWR, vol. 48, no. 12, pp. 243-248.

De Clercq, E. (2006) ‘Antiviral agents active against influenza A viruses’, Nature Reviews Drug Discovery, vol. 5, no. 12, pp. 1015-1025.

Ferguson, N. et al. (2006) ‘Strategies for mitigating an influenza pandemic’, Nature, vol. 442, July, pp. 448-452.

Gordis, L. (2009) Epidemiology, 4th edition, Philadelphia, PA: Saunders Elsevier.

Kretzschmar, M. and Wallinga, J. (2010) ‘Mathematical Models in Infectious Disease Epidemiology’, in: Krämer, A. et al. (ed.) Modern Infectious Disease Epidemiology, New York, NY: Springer Science + Business Media. Polio Epidemiology Case Study Assignment Paper

Lusted, P. and Greene, A. (2015) Childcare rebates could be denied to anti-vaccination parents under new Federal Government laws. ABC News [Online], Available: http://www.abc.net.au/news/2015-04-12/parents-who-refuse-to-vaccinate-to-miss-out-on-childcare-rebates/6386448 [12 Feb 2015].

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M’ikanatha, N. et al. (2013) ‘Infectious disease surveillance: a cornerstone for prevention and control’, in: M’ikanatha, N. et al. (ed.) Infectious Disease Surveillance, 2nd edition, West Sussex, UK: John Wiley & Sons.

Nelson, K. (2014) ‘Epidemiology of Infectious Disease: General Principles’, in: Nelson, K., Williams, C. and Graham, N. (ed.) Infectious disease epidemiology: theory and practice, 3rd edition, Burlington, MA: Jones & Bartlett Learning.

Oxford vaccine Group (undated) Measles [Online], Available: http://www.ovg.ox.ac.uk/measles [12 Feb 2015].

Public Health England (first published 2010) Notifications of infectious diseases (NOIDs) and reportable causative organisms: legal duties of laboratories and medical practitioners [Online], Available: https://www.gov.uk/notifiable-diseases-and-causative-organisms-how-to-report [12 Feb 2015].

Reintjes, R. and Aryna Zanuzdana. (2010) ‘Outbreak Investigations’, in: Krämer, A. et al. (ed.) Modern Infectious Disease Epidemiology, New York, NY: Springer Science + Business Media.

World Health Organization (WHO) (2005). ‘Notification and other reporting requirements under the IHR’, IHR Brief, No. 2 [Online], Available: http://www.who.int/ihr/ihr_brief_no_2_en.pdf [12 Feb 2015].

World Health Organization (WHO). (2010) Statue Commemorates Smallpox Eradication. Available: http://www.who.int/mediacentre/news/notes/2010/smallpox_20100517/en/index.html [12 Feb 2015].

Jeffrey Alba is the eldest son of Jesse and Martha Alba. At twenty-four years of age, he is suffering from a permanent disability. Jeffrey has a poliomyelitis, otherwise known as polio since when he was born. Specifically, he is suffering from spinal polio, a disease that shows no symptoms 90% of the time at its early stages (Fagg, 1990, p. 21) His left leg has completely suffered from muscle atrophy for the past two decades, one of the evidences to the finding that the muscles in the left leg has been receiving little nourishment and exercise due to viral invasion in the spinal column (Beale & Horaud, 2001, p.841). Polio Epidemiology Case Study Assignment Paper

Standing at approximately six feet and weighing at about 75 kilograms, Jeffrey can barely walk without his crutches, and a short-distance walk along the streets of the neighborhood proves to be a tiresome and painful experience for him.

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The Alba family is composed of four members—parents and two siblings. Jeffrey’s sibling is Jennifer, a young girl of sixteen years. The Alba family resides in the suburban area of Detroit, Michigan and has lived there for the length of their lives. The family’s income is a little below the poverty line, living at about $20,000 annually.

The family lives in a rented apartment after their first house was sold in 1990 due to financial difficulties. Client’s Needs Based on the physical configuration of the household’s place, Jeffrey needs the space for him to be able to walk with less hindrance in his path. The fact that Jeffrey walks with the help of his crutches calls for an immediate allocation of sufficient space along the narrow room where the family lives. Unnecessary tables and chairs situated across the living room should be removed or relocated elsewhere where Jeffrey rarely goes.

Other furniture pieces such as cabinets that are too high for the client to be reached should be carefully reconfigured so that the client can be able to reach into those areas with minimal help. Since the rented apartment where the Alba household lives is only a single flat and has no stairs, Jeffrey has no difficulties accessing the other parts of the room except for the fact that there are several tables and chairs that need to be removed from his path. The belongings of Jennifer such as her school bags and books should also be removed from the floor since they can impede the movement of Jeffrey from one place to another. Polio Epidemiology Case Study Assignment Paper

Another observation made is that the rented apartment of the household rests on the fifth floor of the apartment complex. The apartment complex nevertheless has a functional elevator only that there are no emergency power supplies dedicated for powering the elevator during occasional power outages. The apartment complex also has stairs which can be used during emergencies. However, the stairs are steep and prove to be difficult for Jeffrey to use especially when there are other residents using the stairs.

Thus, it is advised that Jeffrey should seek the help from his family in using the stairs in times when the elevators are not functioning. More importantly, the underarm crutches that Jeffrey has been using for the past twelve years have not yet been replaced. Although the crutches are still functioning, the metal bars are already partly bent mainly because of the increase in weight in Jeffrey’s body as he grew up through the years. At six feet in height, the underarm crutches used by Jeffrey for the past six years in his life are only appropriate for individuals with a height of five feet and five inches.

The shorter length of his underarm crutches can result to back complications since Jeffrey has to stoop in order to adjust to the length of the crutches. Moreover, the physical configuration of his underarm crutches is a bit small compared to his physique. Thus, there is an apparent need for a replacement of the crutches in order to prevent several other complications that may arise from the unsuitable crutches that Jeffrey is using. Due to the family’s meager income and budget, Jeffrey has rarely visited a hospital and sought medical advice from a doctor.

The last time that the client visited a doctor was when he was still eighteen years of age, barely six years ago. As a result, the family has no update on the current condition of Jeffrey’s polio. From the family pictures taken within the past six years, it can be observed that the left leg of Jeffrey has greatly decreased in size. While the rest of the body of Jeffrey has developed through the years, the muscles of the left leg of the client have continuously shrunk in mass. The need of the client for medical advice is of utmost importance so that further medical problems can be looked into and averted. Polio Epidemiology Case Study Assignment Paper

Budget for the Changes and Evaluation Most of the proposed changes in the Alba household do not require a significant amount of financial funding. The proposed changes in the setting of the apartment room can be done almost immediately and very minimal help from paid professionals. The parents can transfer the tables and chairs inappropriately situated in the living room into the bedrooms. Meanwhile the school belongings of Jennifer such as bags, books and notebooks scattered in the different parts of the floor can be transferred into the empty cabinets.

The family can easily provide assistance to Jeffrey when he is using the emergency stairs given the fact that the family is oftentimes idle for several hours during the day. Moreover, the parents can request for the construction of a specialized platform just outside the main entrance to the building from the apartment manager or caretaker. The platform will serve as a safety entrance built especially not only for Jeffrey but also for the rest of the other residents of the apartment complex with permanent disability.

The family can also request from the building manager several signs just before the elevator entrance such as signs which inform the public to give sufficient space to or prioritize the permanently disabled residents. This proposed change is also relatively free of charge as far as the Alba household is concerned. There are a few things, however, which need financing on the part of the Alba household in addressing the health condition of Jeffrey. For one, the provision of a new pair of crutches for Jeffrey requires payments ranging from $50 to $100.

Nevertheless, the family can contact several non-government organizations which provide new crutches to deserving individuals either free of charge or at a lesser purchase price. The family can also send personal letters to government officials requesting for a new pair of crutches that are not only sturdy and can last a lifetime but are also suitable to the physique, height and weight of Jeffrey. Given the need for medical advice from a medical practitioner, the family can decide to bring Jeffrey to a healthcare facility that is funded by non-profit organizations. Polio Epidemiology Case Study Assignment Paper

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If possible, however, the family can also resort to medical advice from doctors in private hospitals within Detroit. Medical advice can run to a few hundred dollars, depending on the severity of his spinal poliomyelitis and the equipments which will be used in assessing his condition. As far as the planning, completion and evaluation of the client is concerned with respect to nursing diagnosis, there are little to very minimal expenses which may barely include transportation costs, meal expenses and purchases for documentation purposes.

The duration of the execution of the case study will range from two weeks to a full month, depending on the results of medical advice sought by the Alba household for Jeffrey from either the non-profit healthcare organization or private hospital. The complete valuation will be composed of at least three visits a week to the household for two weeks to one month, with one to two hours duration per visit. Polio Epidemiology Case Study Assignment Paper