Name Student Number

MIDTERM EXAMINATION
EPIDEMIOLOGY 201
SPRING QUARTER 2016

REMINDERS

 Please write your name and student number on this exam and Scantron form.

 Both the exam and Scantron form must be turned in to receive credit for the exam.

 Use your non-programmable hand-held calculators as needed.

 Do NOT use Laptop computers, smartphones, iPods, iPads, cell phones or similar devices during the
test.

 Please turn cell phones OFF.

SCANTRON INSTRUCTIONS

1. Use #2 pencil only

2. Complete following items:

Department & course #: EPI 201

Instructor: BASEMAN
Exam title: MIDTERM
Name: write your name and blacken the circles
Sect: Leave Blank
Student #: write your student number and blacken the circles
Test version: A
Bonus Score: LEAVE BLANK

EXAM INSTRUCTIONS

Please feel free to write on your copy of the exam booklet: do calculations, work out problems, etc.
Only the answer you code on the Scantron Form will count as your final answer.

Blacken in the one bubble on the Scantron answer sheet corresponding to the letter for the one, best answer
from among those offered for each question. There is only one correct answer for each question; multiple
answers marked per question are scored as “incorrect”.

You will have until 11:50am (approximately 80 minutes) to complete the Exam and turn it in.
If you finish early you may turn in the exam booklet and Scantron form, then leave quietly.
 EPI 201 MIDTERM EXAM SPRING 2016

Part 1. Disease Occurrence and Detection

1. At which level of disease surveillance are epidemiologists able to detect an outbreak?

a. Laboratory-based surveillance
b. Syndromic surveillance
c. No formal surveillance
d. A & B
e. A, B, & C

2. Which of the following is NOT a limitation of syndromic surveillance systems?

a. Many diseases have the same signs and symptoms
b. Investigating false positive cases spends valuable public health resources
c. Poor timeliness
d. Evaluating the accuracy of a syndromic surveillance system requires more advanced
surveillance
e. None of the above. These are all limitations of syndromic surveillance systems.

3. A County Public Health HIV surveillance system relies on laboratories to report blood test results on a
monthly basis for patients with HIV. This is an example of:
a. Universal coverage
b. Sentinel coverage
c. Passive surveillance
d. Active surveillance
e. None of the above

4. True or False: A Basic Reproductive Number (R0) of >1 means a disease is no longer spreading.
a. True
b. False

5. True or False: Over the course of an outbreak investigation, the identified populations-at-risk for illness
may change. However, the case definition should remain the same in order to not confuse health care
providers.
a. True
b. False

Use the following answer bank to best characterize the cases of disease described in questions 6-9:
a. Sporadic disease
b. Endemic disease
c. Epidemic disease
d. Pandemic disease

6. The Black Death of the 14th century which swept through Asia and Europe killing an estimated 25
million people.

2
 EPI 201 MIDTERM EXAM SPRING 2016
7. 92 cases of Legionellosis reported in Buffalo, NY during June and July of 2013, compared to a historic
average of 13 cases in Buffalo, NY during June and July.
8. 61 cases per 100,000 persons of pertussis reported in Minnesota in 2012, compared to a historic
average of 60 cases per 100,000 persons per year.
9. Reported tetanus cases have declined more than 99% in the United States since 1947. One case of
tetanus is unusual but does occur from time to time in the US (approximately 0.7 cases per 1 million
population).

10. Which of the following outbreaks would NOT be considered a pandemic?

a. Ebola, 2014-2015
b. H1N1 influenza, 2009-2010
c. HIV, 1981-present
d. Spanish influenza, 1918
e. None of the above. These are all examples of pandemics.

Use the following information about Plague from a 2015 CDC Morbidity and Mortality Weekly Report
(MMWR) to answer Questions 11-16:

“Since April 1, 2015, a total of 11 cases of human plague have been reported in residents of six states: Arizona
(two), California (one), Colorado (four), Georgia (one), New Mexico (two), and Oregon (one). The two cases in
Georgia and California residents have been linked to exposures at or near Yosemite National Park in the
southern Sierra Nevada Mountains of California. Nine of the 11 patients were male; median age was 52 years
(range = 14–79 years). Three patients aged 16, 52, and 79 years died.

Plague is a rare, life-threatening, flea-borne zoonosis caused by the bacterium Yersinia pestis. During 2001–
2012, the annual number of human plague cases reported in the United States ranged from one to 17 (median
= three cases). It is unclear why the number of cases in 2015 is higher than usual. Plague circulates among
wild rodents and their fleas in rural and semirural areas in the western United States. Transmission to humans
most often occurs through the bite of infected fleas or inhalation of respiratory droplets from ill persons or
animals, including ill domesticated cats and dogs. The usual incubation period between exposure and illness
onset is 2–6 days. The mortality rate for untreated plague has ranged from 66% to 93%; however, in the
current antibiotic era, mortality has been reduced to approximately 16%.”

11. What is the agent that causes plague?

a. Wild rodents
b. Yersinia pestis
c. Domesticated cats and dogs
d. Fleas
e. None of the above

12. What is the reservoir of plague?

a. Wild rodents
b. Yersinia pestis
c. Domesticated cats and dogs
d. Fleas
e. None of the above

3
 EPI 201 MIDTERM EXAM SPRING 2016
13. What is the vector for plague?
a. Wild rodents
b. Yersinia pestis
c. Domesticated cats and dogs
d. Fleas
e. None of the above

14. What are the portals of entry for plague into a susceptible human host?
a. Skin
b. Respiratory tract (mouth/nose)
c. Digestive tract
d. Genital tract
e. A & B

15. One of the cases went to their doctor on April 12th, 2015 and reported that symptoms consistent with
plague began on April 8, 2015. Given the incubation period provided in the text above, what was the
likely exposure period?
a. April 8-12
b. April 10-April 14
c. April 6 - April 10
d. April 2 - April 6
e. None of the above

16. Among the cases of plague identified since April 1, 2015, what was the mortality rate? Was the
mortality rate higher or lower than we would have expected?
a. 27.2%, lower
b. 27.2%, higher
c. 81.8%, higher
d. 81.8%, lower
e. 54.5%, about the same as we might expect

Part 2. Outbreak Investigation

Use the following answer bank to answer questions 17-19:

a. Infectivity
b. Virulence
c. Prevalence
d. Relative risk
e. Attack rate

17. A Chipotle restaurant near Boston College served burritos containing guacamole to 278 individuals on
December 5. 43.2% (n=120) of these individuals were diagnosed with Norovirus, allegedly from tainted
guacamole. What does 43.2% represent?
18. Of the 120 people who became ill with Norovirus, only 2% showed severe disease (hospitalization or
death) suggesting this strain of Norovirus did not have high _______________.
19. The term that describes how easily Norovirus is able to enter and multiply within a host is
_____________.

4
 EPI 201 MIDTERM EXAM SPRING 2016

Use the following epidemic curve to answer questions 20-22:

20. What are the minimum, median, and maximum incubation periods, rounding to whole days, for the
disease depicted in the epidemic curve? (Answers are listed as: minimum, median, maximum number
of days).
a. 2, 6, and 12 days
b. 1, 7, and 13 days
c. 2, 8, and 13 days
d. 0, 6, and 12 days
e. 0, 7.5, and 13 days

21. From the epidemic curve, what kind of transmission is most likely occurring?
a. Common source: point source
b. Common source: continuing source
c. Common source: intermittent source
d. Person-to-person: limited spread
e. Person-to-person: propagated spread

22. The conference breakfast was attended by 175 people on December 5. What was the attack rate of
disease X?
a. 20.7%
b. 100%
c. 29.7%
d. Not enough information provided to answer the question

5
 EPI 201 MIDTERM EXAM SPRING 2016
23. During an outbreak of pertussis among university students in Missouri, 88 of 250 students residing in
dormitory A developed pertussis, compared with 23 of 265 residents of dormitory B. What is the relative
risk for pertussis among students who resided in dormitory A compared to those who resided in
dormitory B?
a. 0.71
b. 4.06
c. 3.26
d. 0.80
e. There is not enough information to answer the question

24. In which dormitory was the probability of developing pertussis the highest?
a. Dormitory A
b. Dormitory B
c. The probability was equal between Dormitory A and B
d. There is not enough information to answer the question

25. The measures of disease frequency “incidence” and “prevalence” are related to each other. Which of
the following best explains how the prevalence of a disease could be high but the incidence could be
low?
a. The duration of the disease is short
b. The duration of the disease is long
c. The infectivity of the disease is high
d. The infectivity of the disease is low
e. The disease has a high attack rate

Use the following description to answer questions 26-28:

Cholera Outbreak, South Sudan

On 15 May 2014, the Ministry of Health of South Sudan declared a cholera outbreak in Juba County. The
primary case was retrospectively identified with onset of illness on 23 April 2014. Four cases have been
laboratory-confirmed following tests conducted by the African Medical Research Foundation laboratory in
Nairobi, Kenya. As of 25 May 2014, a cumulative total of 586 cholera cases, including 22 deaths (13 in hospital
and 9 community deaths) have been reported. The majority of the deaths reported in hospital died on arrival.

Given the on-going civil war in the country, the poor prevailing sanitary conditions, the beginning of the rainy
season, and the history of cholera outbreaks in the country, the Ministry of Health of South Sudan continues to
monitor the situation in Juba and surrounding areas.

26. As of March 25, 2014, what was the incidence of cholera in South Sudan?
a. 6.8 per 1,000
b. 18%
c. 3.8%
d. 1.5%
e. Cannot be determined from the information given

27. As of March 25, 2014, what is the case fatality for cholera in South Sudan?
a. 25.0%
b. 3.8%
c. 2.2%

6
 EPI 201 MIDTERM EXAM SPRING 2016
d. 1.5%
e. Cannot be determined from the information given

28. Which of the following is a structural factor that favors the cholera outbreak described?
a. Civil War
b. Rainy season
c. Poor education
d. History of cholera outbreaks
e. None of these are structural factors that favor the cholera epidemic

29. Which of the following groups was NOT identified as being at high-risk for AIDS in the U.S. during the
1980’s?
a. Injection drug users
b. Men who have sex with men
c. Hemophiliacs
d. Infants
e. Haitian immigrants

30. A landmark case-control study was published in 1983 comparing the exposure histories of men who
have sex with men (MSM) with AIDS to the exposure histories of MSM without AIDS. Which of the
following is the best description of the major study finding?
a. Using “poppers” increased the risk of getting AIDS
b. MSM are not the only group of people at risk for AIDS
c. Having a higher number of sexual partners increased the risk of getting AIDS
d. Having any sexual partners increased the risk of getting AIDS
e. There is a risk of getting AIDS through non-sexual contact

7
 EPI 201 MIDTERM EXAM SPRING 2016

FORMULA SHEET

Prevalence = # Cases
# people observed

Incidence = # new cases

# people at risk

Mortality: # deaths
# people at risk

Case Fatality: # deaths

# cases

Diseased Non-Diseased

Exposed A B

Unexposed C D

Relative Risk: Incidence in the exposed / Incidence in the unexposed

(A/(A+B)) / (C/(C+D))