John Snows Investigations

of the Cholera Epidemics in

London, 1848-1854

Source of Information for the

John Snow Example
UCLA School of Public Health,
Department of Epidemiology
Website:
http://www.ph.ucla.edu/epi/snow.html

British cholera epidemics

1831-1832:
- first modern outbreak in Britain
- 23,000 deaths
- helped to launch the sanitary reform movement
1848-1849:
- 250,000 cases and 53,000 deaths
- prompted Snow (and others) to investigate causes

The London Cholera Epidemic of

September 1848 August 1849
Based on his clinical experience and
review of epidemiologic
characteristics of cholera, Snow
formulated a theory of causation and
transmission of the disease.

The London Cholera Epidemic of

September 1848 August 1849
Snows hypotheses concerning cholera:
- a gastrointestinal disease, therefore causal
agent was likely ingested
- diarrhea as most prominent symptom,
therefore causal agent likely left the body
by this route
- if cholera excretions contaminated rivers
from which drinking water was taken, then
the disease could be widely disseminated

The London Cholera Epidemic of

September 1848 August 1849
Causal Hypothesis:
Sewage-contaminated drinking
water was a causal agent for the
cholera epidemic.

The London Cholera Epidemic of

1848-1849
Snow tested this hypothesis by first
conducting an ecologic study of London
districts using:
- routine surveillance data on cholera cases
- population data at the district level
- available information on water companies
serving the districts
- available data on property values by district

The London Cholera Epidemic of

1848-1849
Characteristics of an ecologic study:
- unit of analysis is not the individual or case
- unit of analysis is a geographical unit such as a
district or neighborhood or city or county
- useful to initially study a cause-effect relationship
when data are easily available and/or an individual
level study is not feasible
- does not directly link an individual case to an
exposure (unless everyone in the geographical
unit has a similar exposure)

The London Cholera Epidemic of

1848-1849
Snow did not have exact information on
the sources of water for the districts.
However, Snow knew that:
- the East and South districts were served by
water supplies obtained from known polluted
parts of the Thames River
- the rest of London received drinking water
relatively uncontaminated by sewage.

Districts
of
London

Population
in
1841

Deaths
from
Cholera

West

300,711

533

1.77

North

375,971

415

1.10

Central

373,605

920

2.48

East

392,444

1,597

4.06

South

502,548

4,001

7.95

1,948,369

7,466

3.83

Total

Deaths
to each 1,000
inhabitants

Deaths from Cholera in London; Registered from

September 23, 1848 to August 25, 1849

The London Cholera Epidemic of

1848-1849
Limitations of ecologic study:
- Uncertainties about districts water supplies
-

some residences used water pumps

some districts served by more than one company

- Districts may vary by socioeconomic (SES)

factors
- Dont know if cholera cases actually drank
contaminated water

The London Cholera Epidemic of

1848-1849
Most of southern districts were served by
two water companies, both using sewagecontaminated water from Thames River.
- Southwark and Vauxhall Water Company
- Lambeth Water Company

In 1852, Lambeth Water Company

moved its intake to an uncontaminated
part of the Thames River

Cholera death rate in London

according to water company
supplying district of residence
(August 1853 January 1854)

Water Company
Southwark & Vauxhall and
Kent

Deaths from cholera in

100,000
107

Sourthwark & Vauxhall

94

Lambeth and Southwark &

Vauxhall

61

Cholera death rate in London

according to water company
supplying sub-district of residence
(August 1853 January 1854)

Water
company

Population Deaths from Deaths in

in 1851
cholera
100,000

Southwark & 167,654

Vauxhall
12 sub-districts

192

114

Both
301,149
companies
16 sub-districts

182

60

Lambeth
3 sub-districts

14,632

 Ecologic study of districts and subdistricts could not rule out:

- confounding by socio-economic (SES)
factors.
- Exposure misclassification (e.g., public
wells)

Ecologic study could not link cases with

exposure. (Cases may not have drunk
contaminated water.)

The natural experiment:

16 sub-districts served by both water
companies, with pipes from both
companies going down every street,
serving residences in a virtually random
fashion.

The natural experiment:

individual-level study

The natural experiment:

shoe-leather epidemiology
Home of each case was visited to determine
source of water to the residence:
- next-of-kin recall found to be inadequate
- confirmation by water bill receipt or by water
sample.

Reports from water companies provided

denominator information (# houses supplied in
each district)

The natural experiment

The preceding table included:
- districts served by both companies in an
intermingled fashion (i.e., the natural
experiment) and
- districts served by only one of the
companies.
- the relative risk = 315/ 37 = 8.5

The natural experiment

Because Snow combined both districts with
and without intermingled supplies,
confounding bias by SES factors was still
possible:
- the districts served only by Lambeth Co. were
wealthier than those served only by Southwark &
Vauxhall.

When Snow later focused only on the

districts with intermingled supplies, the
relative risk fell from 8.5 to 6.9.

The Broad Street Pump

Outbreak

INSTANCES OF THE COMMUNICATION OF CHOLERA THROUGH THE

MEDIUM OF POLLUTED WATER IN THE NEIGHBORHOOD OF BROAD
STREET, GOLDEN SQUARE
(August 31 September 9)

The most terrible outbreak of cholera which ever occurred in this

kingdom, is probably that which took place in Broad Street, Golden
Square, and the adjoining streets, a few weeks ago. Within two hundred
and fifty yards of the spot where Cambridge Street joins Broad Street,
there were upwards of five hundred fatal attacks of cholera in ten days.
Source: Snow J. On the Mode of Communication of Cholera, p 38.

The Broad Street Pump

Outbreak
Snow began the investigation with:
- a hypothesis from his previous work
-

sewage-contaminated drinking water is a

cause of cholera

- a working knowledge of the cluster area

(he resided nearby).

The Broad Street Pump Outbreak

Piped water not contaminated by sewage.
Water samples on 9/3 from pumps near Golden
Sq. found that all except the Broad St. pump
had visible impurities.
However, local residents reported foul smells
from the Broad St. pump water the day before
the pump samples were taken.
Days later, small flocculent particles were
detected in Broad St. sample.

The Broad Street Pump Outbreak:

difficulties of exposure assessment
Variability in sampling results over time

sampling a day earlier may have found visible

contamination in Broad St pump water

Uncertainties about relevant contaminant

- visible particles seen immediately?
- flocculent particles seen days later?

High or unknown detection limits

Lack of information on contaminant sources
(e.g.,local cesspool near pump)

The Broad Street Pump Outbreak:

case series evaluation
61 of 73 cases drank water from the Broad
St. pump; 6/73 did not; 6/73 unknown.
2 cases living far from the area used water
from the Broad St. pump.
No outbreak among those in the outbreak
area who did not use Broad St. pump
- 5 deaths among 535 inmates
- 0 deaths among 70 brewery workers

Cholera outbreak in Golden Square,

Broad Street, London 1854

Lessons from Snows

Investigations
Based on review of what was known about
cholera, Snow formed a hypothesis:
- sewage in drinking water causes cholera

Snow tested hypothesis using available data

to conduct an ecologic study comparing
cholera rates in districts and subdistricts

Lessons from Snows

Investigations
Snow recognized the limitations of the
ecologic study:
- could not directly link individual cases to exposure
to contaminated drinking water
- alternative explanation for findings: confounding
by SES factors

Lessons from Snows

Investigations
Snow identified a study area and study
population that:
- provided an excellent exposure contrast (high
vs no exposure)
- minimized confounding by SES factors
-

districts with intermingled supplies of high and low

contamination serving homes in a virtual random
fashion - a natural experiment

Lessons from Snows

Investigations
shoe-leather epidemiology approach
to case verification & exposure
assessment:
- visiting the homes of the cholera cases
- obtaining verification of source of water for
each case residence (receipt, water
sample)

Lessons from Snows

Investigations
collected denominator data from water
companies in order to calculate disease
rates among exposed and unexposed.

Lessons from Snows

Investigations
Explored alternative explanations:
- focused on districts with intermingled supplies to
minimize confounding by SES factors
- in the cluster investigation, Snow identified:
-

brewery workers and inmates unexposed to the

contaminated water but worked in cluster area in order to
rule out air pathway of exposure
high SES cholera cases living far from the cluster area
whose only link to the cluster was drinking from Broad St
pump

Lessons from Snows

Investigations
Snow found an association between
exposure and disease and used this
information for prevention
Snow utilized tables and maps to present a
strong case for a causal relationship between
sewage-contaminated drinking water and
cholera