Article Analysis Tamara Putney Ferris State University

2 Article Analysis CCHS 315 Title of Article Analyzed: A Waterborne Outbreak of Escherichia coli O157:H7 Infections and Hemolytic Uremic Syndrome: Implications for Rural Water Systems. Sonja J. Olsen, Gayle Miller, Thomas Breuer, Malinda Kennedy, Charles Higgins, Jim Walford, Gary McKee, Kim Fox, William Bibb, and Paul Mead. As reported in April 2002, Vol. 8, No. 4, Emerging Infectious Diseases, access at http://wwwnc.cdc.gov/eid/article/8/4/000218_article.htm on November 18, 2011. Summary In the summer of 1998 in Alpine, Wyoming a large outbreak of Escherichia coli O157:H7 occurred as evidenced by physician reported increases in bloody diarrhea among town residents. The town has less than 500 residents but it is a popular vacation spot due to nearby Grand Teton and Yellowstone National Parks. On July 11 the CDC and Wyoming health officials began investigation of the cases. Two cohort studies were carried out, one with the residents of Alpine and another with the visitors to a large family reunion that was held in the town during Jun 26 to 28. For hypothesis generation, interviews were conducted and stool and serum samples were taken from as many people as possible targeted as being involved, in the area or exposed to municipal drinking water from June 25 to July 1 . Environmental samples from the area were also taken and sent to the laboratory. The case definition developed for the Alpine residents study was a) stool culture yielding E.coli O157:H7, or b) diarrhea (>/=3 stools in a 24 hour period with onset after Jun 25 in any resident who was in town between Jun 25 through July 1). The case definition for the family reunion study was any person who attended the reunion and had >/=3 stools in a 24hour period with onset after June 26. Questions were focused on when the people were in the town and what they came in contact with in the

3 environment as well as what food and water they drank and where it came from. A variety of lab tests were performed on the stool samples including pulsed-field gel electrophoresis (PFGE). PFGE allows for DNA fingerprinting, when uploaded to a large CDC accessible database and can isolate strains of disease causing bacteria. This allows for comparison of previously identified strains in humans or food, which allows for more rapid recognition and prevention of disease spreading (CDC, 2011). Serum was also collected from study participants to test for the levels of immunoglobulin IgG and IgM antibodies. Titer results > 1:160 for IgG and >1:320 for IgM were considered positive. Environmental samples were taken from the Alpine Municipal water system, including storage tanks and supply lines. Samples were also processed from nearby elk and deer fecal matter found above a spring collection system for the municipal water supply. Study and test results revealed 157 ill persons ( from 15 different states), and stool from 71 people tested positive for E.coli O157:H7. Illness onset ranged from June 25 to July 27 (stool culture positive) and June 22 to July 30 (stool culture negative stools). No deaths were reported, and four persons developed hemolytic uremic syndrome. Food was ruled out as a source of illness. Illness was significantly associated with ingestion of municipal drinking water and the visitors showed a higher attack rate (50%) versus town residents (23%) who were exposed to the water (p=<0.01). Interestingly, the attack rate decreased with increasing age of the town residents. This was related to partial immunity developed due to prolonged exposure. The chlorinated water supply had microbiological evidence of fecal organisms and the potential for chronic contamination with surface water (Olson et al., 2002). Overall this study illustrates the potential danger for contamination of public water supplies as a potential public health risk that could rapidly spread disease across the nation.

4 1. Name of Statistic: Attack Rate Was this statistic covered during the class? Yes Number of times used in the article: Attack rate reference was made 5 times. Overall attack rates were calculated in each cohort studies then the attack rate in the Alpine study compared male to female attack rates (which showed no significance). The Alpine study also showed attack rates for different 3-day periods, which helped narrow the window of when the most contraction of disease occurred. For the Alpine residents it was during the Jun 26-28 period. The last attack rate mentioned was the major overall attack rate that referred to a frequency distribution table that showed the age distribution of disease for the two cohort studies, this is where the pvalue was used. Why do you think the statistic was used? An attack rate is a form of incidence that measures the proportion of persons in a population who experience an acute health event during a limited period (e.g., during an outbreak), calculated as the number of new cases of a health problem during an outbreak divided by the size of the population at the beginning of the period, usually expressed as a percentage or per 1,000 or 100,000 population (CDC Principles, n.d.). In this article, this statistic is expressed as a percentage and used to compare the incidence rates of water exposure persons having E. coli in the town residents versus the family reunion attendees. What did the statistic show or prove: The statistic proved that the attack rate of family reunion persons exposed to contaminated water was higher than that of the

5 Alpine residents. In other words, visitors that drank the water were more likely to get sick than residents who drank the water; 23% versus 50%. Was there an associated P value? Yes If yes, what was the P value and what did the P value show? p=<0.01, a P value indicates the probability that test results are wrong or inaccurate. A very low value of <.01 indicates a highly significant likelihood that the results are very reliable. In contrast, had the P value been >.05 the attack rate findings would not be significant or reliable (Besey, 2011). In this case it lets us say with high certainty that the test is true, that visitors to the town are more likely to get sick from the contaminated water than the residents of the town. 2. Name of Statistic: Relative Risk Was this statistic covered during the class? Yes Number of times used in the article: 2 Why do you think the statistic was used? Since relative risk shows the probability that a member of an exposed group, in this case the people exposed to the municipal drinking water, will develop a disease relative to the probability that a member of an unexposed group, those not drinking the water, will develop the same disease; this stat was used to show the risk of drinking the water and getting sick (Triola, 2006, p. 129). The two groups that were compared were the out of town residents and the people who live in the town on a permanent basis. What did the statistic show or prove: This stat proved that out of town visitors, the family reunion attendees, if exposed to the municipal drinking water, were more likely to get sick than those exposed people who lived in the town, the Alpine

6 residents. RR=9.0, a RR>1.0 is significant. Relative risk was also used to narrow down what the risks were to all possible sources of the E.coli in the environment. This was used in each of the cohort studies. For example, in the Alpine group (when looking at the proportion of exposed versus non exposed), drinking municipal water June 26-28 was 8.2x more likely to cause sickness than any other environmental factor. Was there an associated P value? No If yes, what was the P value and what did the P value show? N/A 3. Name of Statistic: Confidence Interval Was this statistic covered during the class? Yes Number of times used in the article: 6 Why do you think the statistic was used? A confidence interval (CI) is a range or an interval of values that can be used to estimate the true value of a population parameter (Triola, 2006, p. 259). In other words, it is an indicator of the measures precision. It can be used for a proportion, rate, risk ratio, and other measures, but all are calculated using different formulas (Besey, 2011). The confidence interval used in this study was for 95%. A narrow CI indicates high precision, a wide CI indicates lower precision. CI was used in this study to confirm the precision of the measures of illness being associated with drinking water in the town of Alpine. What did the statistic show or prove: This statistic showed the range of precision for drinking water being the cause of illness, and it was also used to show the CI for the relative risk associated with all environmental cause comparisons. It helped confirm and isolate drinking water as the source of contamination.

7 Was there an associated P value? No If yes, what was the P value and what did the P value show? N/A 4. Name of Statistic: Kaplan Meier Survival Analysis Was this statistic covered during the class? No Number of times used in the article: 1 Why do you think the statistic was used? Kaplan Meier Survival Analysis is a survival analysis used to produce a curve of survival times of members of a group over time (Walker, 2011). In this study this test was used to compare the fecal shedding times of adult members in a group and child members in a group. This analysis produced curves which were then compared using the Logrank Test. This survival analysis test is useful when the predictor variable is categorical, or takes a small number of values that can be considered to be categorical (Walker, 2011). What did the statistic show or prove: This test was only referenced as being used, no results or mention of the test was noted. I can only assume the results of the median duration of fecal shedding was 9 days among children and 7.5 for adults were the results of these curves. Not much information was provided in the article. Was there an associated P value? No If yes, what was the P value and what did the P value show? N/A 5. Name of Statistic: Log Rank Test Was this statistic covered during the class? No Number of times used in the article: 1 Why do you think the statistic was used? The log rank test is used to compare two or more sets of data on survival times over time (Walker, 2011). In this case this

8 statistical test was used to compare data for adults versus children related to the minimal duration of fecal shedding of E. coli in those subjects with positive stool samples from both cohort groups. The time between the onset of symptoms to the last positive stool test before two negative test results of group members was examined using the Kaplan-Meier survival analysis test- the log rank test was then used to compare those curves of each of the groups. What did the statistic show or prove: This test was only referenced as being used, no results or mention of the test was noted. The median duration of fecal shedding was 9 days among children and 7.5 for adults, the difference was not statistically significant as the P value = 0.63. From the article I cannot be sure if this p value was specifically associated with the Logrank Test or some other analytical or statistical test. The Logrank Test is used to compare groups to each other in terms of survival times. Was there an associated P value? Possibly, see above. If yes, what was the P value and what did the P value show? N/A 6. Name of Statistic: Median Was this statistic covered during the class? Yes Number of times used in the article: 3 Why do you think the statistic was used? When a data set is put in rank order, the median is the middle value. It divides the data in two halves, it is also the 50th percentile of the distribution (CDC Principles, n.d.). It is a good descriptive measure, especially for skewed data, it shows the central point of the distribution, and is not generally affected by extreme outliers. It is used in this study to identify

9 median age in each of the cohort study groups, and the median time for fecal shedding. This statistic was likely used because the age ranges were very wide, <1 to 92 years of age and the fecal shedding times were relatively wide, 1-36. What did the statistic show or prove: This statistic showed the half way point or middle 50th percentile of the age groups in the cohort study, and the middle or median point of fecal shedding for the bacteria in days. Was there an associated P value? Yes If yes, what was the P value and what did the P value show? p=0.63 shows a difference that equates to the adult and children fecal shedding times not being statistically significant. 7. Name of Statistic: Odds Ratio Was this statistic covered during the class? Yes Number of times used in the article: 2 Why do you think the statistic was used? The odds ratio is a measure of risk from the ratio of the treated or exposed group to the odds for the control group (Triola, 2006, p. 132). This statistic was used to show that drinking municipal water was significantly associated with illness when comparing those who drank the water and got ill to those who did not drink the water and got ill. What did the statistic show or prove: The OR was 10.1. An OR>1.0 is significant. This proved that illness was significantly associated with drinking municipal water for both town residents and family reunion persons. Was there an associated P value? No If yes, what was the P value and what did the P value show? N/A

10 8. Name of Statistic: Kruskal-Wallis Test Was this statistic covered during the class? No, but one way ANOVA was discussed in class. Number of times used in the article: 1 Why do you think the statistic was used? This test is a one-way analysis of variance (ANOVA). It is most often used when there is one nominal variable and one measureable variable (McDonald, 2009). In this study it was used to compare the average number of glasses of water drank being associated with the risk of illness. An ANOVA is similar to a t test except that it compares the populations of three or more groups from one experiment (Besey, 2011). This one-way ANOVA compares multiple groups that receive a treatment. What did the statistic show or prove: This statistical test showed that among the persons who drank the municipal water the average number of glasses of water and the risk for illness was not statistically associated. Was there an associated P value? Yes If yes, what was the P value and what did the P value show? P=0.7 this equates to not statistically significant. To be significant the p would have to be <.05. 9. Name of Statistic: Geometric Mean Was this statistic covered during the class? Yes Number of times used in the article: 1 Why do you think the statistic was used? This statistic is the mean or average of a set of data measured on a logarithmic scale (CDC Principles, n.d.). The geometric mean is very useful in laboratory data from serial dilution assays and as part of

11 environmental sampling (CDC Principles, n.d.). Geometric mean was used in this study because it was used with serum titers, which can range over several orders of magnitude. This is the statistical measure of choice for titers or assays. What did the statistic show or prove: This study used the geometric mean of IgG antibody titers to correlate findings that suggest that Alpine residents have titers that prove long term exposure which developed into a degree of immunity to the bacteria. Even residents who did not drink the water (38% of sample) showed rarely high titers (>1:160), only 3-4% of well persons in the U.S. show IgG titers that high without disease. Was there an associated P value? No If yes, what was the P value and what did the P value show? N/A

12 References Besey, K. (2011). CCHS 315 Class Learning Module. Center for Disease Control and Prevention [CDC]. (n.d.). Principles of epidemiology in public health practice (3rd edition). Retrieved from http://www.cdc.gov/training/products/ss1000/ss1000-ol.pdf Center for Disease Control and Prevention [CDC]. (2011). What is pulsnet?. Retrieved from http://www.cdc.gov/salmonella/typhimurium/pfge_process.html McDonald, J. H. (2009). Handbook of biological statistics: Kruskal wallis test and mann whitney u test. Retrieved from http://udel.edu/~mcdonald/statkruskalwallis.html Triola, M. M., & Triola, M. F., (2006). Biostatistics: For the biological and health sciences. Boston, MA: Pearson Education. Walker, M. (2011). Statistics consulting. Retrieved from http://walkerbioscience.com/pdfs/Survival%20analysis.pdf