Case 6.

Epidemic asthma

Learning objectives:
1. Developing a case definition
2. Interpreting descriptive data
3. Constructing histograms
4. Plotting the distribution of cases
5. Constructing 2x2 tables
6. Calculating risk ratios (odds ratios)
7. Identifying intervention strategies for prevention

PART 1 - INTRODUCTION

Barcelona is a city of 1.7 million situated on the Mediterranean Sea.

During the last week of January 1986, several physicians contacted public health authorities to
report an increase in the number of persons who had come to the emergency rooms of the four
large urban hospitals seeking medical care for acute severe asthma. Specifically, on Tuesday 21
January 1986 a total of over 130 people had sought care at these hospitals for difficulty in
breathing. Most of these people were thought to be suffering asthma attacks. The attacks struck
very suddenly and caused such severe problems that 10% of the patients required ventilatory
support and 2% died.

Question 1: What is asthma?

Question 2: Is this an epidemic of asthma? What further information do you need?
Question 3: Review of the hospital records reveals that the four hospitals treated 288
persons with asthma during the month of January 1986. Now can you determine if this is
an epidemic?

Question 4: Develop a preliminary case definition.

Question 5: Do you now have sufficient information to determine if there is an epidemic of
asthma (Table 1)?

Number

165

128

138

124

Question 6: Print the attached graph paper and draw a bar-chart of the data tabulated
above in Table 2. What additional information does the bar-chart provide?
Graph Paper

Day

Number

14

15

16

17

18

19

Question 7: What other information would be useful to characterise the epidemic?

Question 8: On the attached city map, using dots, show the geographic distribution of the
place of onset of illness (Table 3) for the 96 persons who came to the emergency rooms with
acute asthma on 21 January. What does this distribution suggest?

Table 3.
Age, sex, time and place of onset of illness, for each of the persons who came
to the emergency room with acute asthma on 21/01/1986.
Ag Se Time of
e x onset
41
28
27
40
30
19
17
40
28
49
47
29
28
38
49
59
39
40
59
41
10
27
27
20
27
18
30
48
30

F
M
M
F
F
F
F
M
M
M
F
M
F
M
F
M
M
M
M
M
M
F
M
F
M
F
M
M
F

10:55
12:50
13:40
12:00
13:25
02:20
11:05
17:15
13:50
17:10
14:30
11:10
14:30
11:35
18:20
22:10
11:25
11:05
21:20
11:08
23:15
12:05
12:40
09:25
11:40
12:30
12:15
16.50
12:25

Place of
onset
(Region)
4
2
2
3
2
3
2
1
2
1
1
2
2
1
3
6
1
1
3
10
7
2
2
8
2
2
2
2
2

Age Sex Time of

onset

Place of onset (Region)

40
41
28
48
29
30
27
57
28
30
29
29
50
30
41
40
57
47
58
41
48
69
40
27
47
89
49
29
19

3
10
2
1
2
2
2
2
2
2
2
2
2
2
4
2
2
2
2
4
2
2
2
2
2
2
2
2
1

M
M
F
F
M
M
F
M
M
F
F
M
M
F
M
F
F
M
M
F
F
M
F
F
M
M
F
F
F

10:00
10:08
13:30
16:30
13:10
13:15
14:05
14:40
14:50
11:25
14:20
14:10
14:15
14:25
12:55
15:25
15:05
15:40
15:50
11:50
15:30
15:10
15:25
13:05
16:50
12:10
15:20
12:20
17:20

29
37
38
39
40
37
41
40
37
38
38
39
39
40
15
18
70
18
50

F
M
M
M
M
F
M
M
M
M
F
F
M
M
F
M
M
F
M

13:20
12:17
12:35
12:25
12:05
11:30
12:08
19:15
10:17
10:35
10:45
10:25
10:25
10:05
23:25
00:50
15:15
00:30
11:15

2
1
1
1
1
1
10
6
1
1
1
1
1
1
6
3
2
7
2

67
40
29
78
68
19
38
48
37
49
38
40
59
60
19
20
47
67
28

F
F
F
F
M
F
M
F
M
M
F
F
M
M
M
M
M
M
M

12:30
17:25
11:20
11:30
12:45
12:25
18:50
18:30
11:17
19:10
11:45
19:25
11:25
11:00
05:10
06:15
15:30
16:40
11:50

1
1
2
2
1
1
1
10
1
3
1
7
1
3
3
8
1
2
2

Question 9: Print the attached graph paper and draw a bar-chart of the cases by hour of
occurrence (Table 3). What hypotheses are suggested?
Graph Paper

PART 2

In your discussions with emergency room personnel, you learn that this is not the first time that
the hospitals have been overwhelmed with patients suffering from acute asthma attacks. You are
told that "asthma epidemic days" have occurred on 12 other occasions during the last 2 years.
Noting the clustering of asthma emergency room visits in space and time, you request data on air
pollution in the city during the past two years. For Tuesday 21 January, air pollution levels were
below normal for the city. The 24-h average level of sulphur dioxide was 54 g/m3 and that of
black smoke was 98 g/m3. The highest hourly mean for nitrogen dioxide was 10 ppb. Twentyfour hour pollen and spore counts were also below average for that time of year. Meteorologic
data showed high atmospheric pressure and stagnancy of the air with a very low wind speed.

Question 10: What conclusions can you draw from this information?

Since many persons reported that they were affected in the centre of the city, near the waterfront,
you decide to find out more information about the activities there. You learn that the following 8
products were either loaded or unloaded from barges and books in the harbour during the last
two years.
Coal
Cotton
Gasoline
Soybeans
Fuel oil
Coffee
Corn
Butane
Question 11: How would you use this information to further explore this problem?

You ask for dates on which each of these products were loaded or unloaded from barges or boats.
This information is shown in Table 4.
Table 4
Days Product is Handled
(Loaded or Unloaded)

Days Product is NOT Handled

(Loaded or Unloaded)

Asthma Epidemic Days

Asthma Epidemic Days

Product
NO

YES

NO

YES

196

521

150

567

10

180

537

11

399

318

300

417

135

582

12

249

13

468

140

577

12

Coal

Fuel Oil

Gasoline

Cotton

Coffee

Corn

Soybeans

Butane

Question 12: Using the information in Table 4, print and complete the following tables and
calculate a risk ratio and confidence interval (C.I) for each table (use the formulas
presented in class discussion. Also, the computer software EPIINFO will be demonstrated
to calculate confidence intervals).

Two by Two Tables Based on Table 4.

Unloading Coal
Yes
Epidemic
Asthma

No

Yes

No

Day
No

No

Unloading Fuel Oil

Unloading Soybeans
(1)

Yes

No

Yes

No

Epidemic
Asthma
Yes

Yes

Day

Day
No

No

Unloading Gasoline

Unloading Soybeans
(2)

Yes
Epidemic
Asthma

Yes
Epidemic
Asthma
Yes

Day

Epidemic
Asthma

Unloading Corn

Yes

No

Yes No
Epidemic
Asthma
Yes

Day

Day
No

No

Unloading Cotton
Yes
Epidemic
Asthma

Unloading Butane

No

Yes No
Epidemic
Asthma
Yes

Yes

Day

Day
No

No

Unloading Coffee
Yes
Epidemic
Asthma

No

Yes

Day
No

Question 13: How do you interpret the risk ratios and confidence intervals you have
calculated?
Question 14: Now substitute a 1.0 for the 0 in cell B (soybeans) and re-calculate.
Question 15: How would you proceed from here?

PART 3

Question 16: Develop a strategy for prevention of asthma epidemics in the city.
Question 17: How would you assess the costs of this prevention strategy compared to the
costs of the emergency visits for asthma attacks?
Based on a report by Anto, J.M. et al. Community outbreaks of asthma associated with inhalation of soybean dust.
The New England Journal of Medicine, 1989, 320(17): 1097-1102
For further study of methodology for epidemiologic studies of asthma, the following review article is recommended:
Anto, J.M. & Sunyer, J. Epidemiologic studies of asthma epidemics in Barcelona. Chest, November, 1990
(Supplement): 185s-189s.