Disease Detectives

Division B Event

Part B: Fun at the Child Care Center

2014 National Science Olympiad Tournament

University of Central Florida
Orlando, Florida
May 17, 2014

Developed by
Centers for Disease Control and Prevention (CDC)
U.S. Department of Health and Human Services

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Acknowledgements
This scenario presented in this Disease Detectives event is hypothetical. To the best of our knowledge,
there was no outbreak of asthma in Orlando during spring of 2012. It is adapted from a case-study
(given as a reference) based on an actual outbreak in Barcelona, Spain. The event was developed by
CDC subject matter expert:

Ralph Cordell, Ph.D.

Epidemiologist
Division of Scientific Education and Professional Development
Center for Surveillance, Epidemiology, and Laboratory Services

Scientific and editorial review was provided by Ralph Cordell, Ph.D. and Kelly Cordeira, M.P.H. from
Career Paths to Public Health, Division of Scientific Education and Professional Development, Center
for Surveillance, Epidemiology, and Laboratory Services, Office of Public Health Scientific Services.

Suggested citation
Centers for Disease Control and Prevention (CDC). Disease Detectives Event—2014 National
Tournament. Atlanta, GA. Available at: http://www.cdc.gov/diseasedetectives/.

Contact Information
Please send questions and comments to [email protected].

Disclaimers
This Disease Detectives Event is in the public domain and may be used without restriction.
Citation as to source, however, is appreciated.

Links to nonfederal organizations are provided solely as a service to our users. These links do not
constitute an endorsement of these organizations nor their programs by the Centers for Disease Control
and Prevention (CDC) or the federal government, and none should be inferred. CDC is not responsible for
the content contained at these sites. URL addresses listed were current as of the date of publication.

Use of trade names and commercial sources is for identification only and does not imply endorsement by
the Division of Scientific Education and Professional Development, Center for Surveillance,
Epidemiology, and Laboratory Services, CDC, the Public Health Service, or the U.S. Department of
Health and Human Services.

The findings and conclusions in this Disease Detectives Event are those of the authors and do not
necessarily represent the official position of the Centers for Disease Control and Prevention (CDC).

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 2014 Division B

Part B: Fun at the Child Care Center

It is a warm Monday morning in mid-September. You are the chief epidemiologist at a large city health
department. As you review reports electronically transmitted to your office during the weekend, the phone rings.
The caller is Beth Grey, director of Child Care Facility A, a child care center in your jurisdiction. Beth says she
received a call from the parents of a young boy who was hospitalized during the weekend with severe diarrhea
and dehydration. She says her staff has noticed a slight increase in the number of children with loose stools during
the last few weeks. The staff was not too concerned because the stools were not bloody, and pediatricians were
telling parents the diarrhea was because of teething, food allergies, or antibiotic use.

1. (1 point) Which of the following represents a key component of the definition of an outbreak? (circle
the best answer)
a. The outbreak happens suddenly.
b. The outbreak involves a numerous persons.
c. Certain persons are hospitalized or die.
d. More cases than expected are reported.
e. The outbreak is caused by an infectious agent.
f. The outbreak is widespread.

2. (1 point) Which of the below pieces of information would be most helpful to determine if this represents
an outbreak? (circle the best answer)
a. The causative agent.
b. The source of infection.
c. The index case,
d. The number of children who had diarrhea during the same period last year.
e. The number of secondary cases.
f. None of the above.

You ask Beth for the child’s name, age, hospital where he was admitted, his pediatrician’s name, whether she
knows of any laboratory results, and the last date the boy attended the center. Beth tells you the child is 3 years
old and is at Children’s Hospital under the care of Dr. Brown. She replies that she does not know what kind of
tests were done. The boy last attended the child care center on the previous Thursday and was well that day. You
have worked with Dr. Brown and know him to be an excellent physician who understands public health as well as
clinical medicine. However, you are concerned about the recent increase regarding children with diarrhea at Child
Care Facility A and need more information before you can develop a hypothesis.

3. (1 point) Which of the following is the most important question you would ask about the children with
diarrhea to understand place? (circle the best answer)
a. Where do they live?
b. What classroom is each child in?
c. Have they traveled out of the area?
d. What other exposures did they have in the week before they became ill?

4. (1 point) Which of the following is the most important question you would ask about the children with
diarrhea to understand time? (circle the best answer)
a. When was the last day they were at the center?
b. What time of day did they become ill?
c. When did they first attend the center?
d. What day did they become ill?

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You tell Beth that you have to get ready for a meeting. Before you end the call, you ask Beth to provide
information concerning the number of children with diarrhea at the child care center for the previous 8 weeks of
this year and the same period last year. For each week, you need the number of children with diarrhea and the
number who attended at least one day during that week. Beth says she will have someone get right on it and send
the information to you in a spreadsheet by e-mail. When your meeting is over, you check your e-mail and find
Table 1 from Beth.

Table 1: Number of Children with Diarrhea* and Number of Children Present** at Child Care Facility A, by
Weeks 29–36, 2012 and 2013***

Week Week Week Week Week Week Week Week Total

29 30 31 32 33 34 35 36
2012
No. with 1 0 3 2 0 4 1 2 13
Diarrhea
No. Present 134 143 138 132 139 141 137 136 1100
2013
No. with 2 1 3 1 1 3 7 14 32
Diarrhea
No. Present 142 139 137 141 143 138 144 140 1124
*
Includes those recorded by child care providers and reported by parents during daily health checks.
**
A child was considered present if he or she attended at least one whole day during the week.
***
Health department was notified at start of week 37.

5. (3 points) Calculate the incidence of diarrhea per 100 child-weeks during weeks 29–36 in 2013. (Hint:
The number of child weeks is the same as the number of children present each week)

6. (2 points) Determine the relative risk (RR) for diarrhea during 2013, compared with 2012.

You review the data in Table 1, call Dr. Brown’s office, and ask his nurse about the boy admitted to Children’s
Hospital. She says the child was admitted for acute dehydration resulting from watery diarrhea and vomiting. He
responded well to treatment and was sent home a few hours ago. A stool sample was collected when the child was
admitted Sunday and test results should be available within a day or so. The initial diagnosis was viral diarrhea or
possible cryptosporidiosis — definitely not related to teething or antibiotics. You thank her for the information.
You ask whether the hospital lab can speed up the testing and call you as soon as they get results. The nurse says
she will do her best.

You call Beth to tell her that on the basis of the information she sent, a problem might have developed. She says
they have had a terrible day so far. One of her teachers went home ill and at least three more children developed
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diarrhea. In one of the 4-year-old classrooms, a child had feces running down her leg. She says one child had the
same symptoms the week before last, got better, and is sick again. You tell her that you spoke with Dr. Brown’s
office and it appears a communicable disease outbreak at the center might be occurring, and you will put together
a team to visit this afternoon. You ask Beth to break down the data she sent by classroom and create a table
showing the number of children with diarrhea and number of child-weeks of attendance for each classroom 8-
week period. You explain to her how to calculate child-weeks of attendance.

7. (1 point) Which part of the descriptive epidemiology triad are you addressing by looking at the data by
classroom?

You contact the Environmental Health and Nursing units of the health department, explain the situation, and ask
them to assign a sanitarian and public health nurse to accompany you on a field visit. You next contact the local
office of the child care licensing agency to let them know what is going on and what you plan to do, and invite
them to send a representative along on the field visit. Finally, you call your colleague Larry Johnson at the state
laboratory and talk with him about the situation. “You know, Dr. Brown may well be right on this one,” Larry
says. “Several types of viruses cause watery diarrhea. Rotaviruses and noroviruses are the most common. A
vaccine is available for rotavirus, and norovirus outbreaks tend to be really explosive. This outbreak seems a bit
like a slow burner. That kid who was sick, got well, and then is sick again sure sounds like a recrudescent case.
We see that a lot with Crypto 1. Why don’t you stop by and pick up some stool collection kits? We can test for that
here.”

8. (2 points) List two steps of an outbreak investigation that were addressed in the previous paragraph.

You tell your secretary that you will probably be at Child Care Facility A all afternoon. You meet Bill Rosales,
the sanitarian, and Marge Kunith, the public health nurse, in the parking lot and give them the address. You tell
them a colleague at the state laboratory thinks this might be a cryptosporidiosis (Crypto) outbreak and you are
going to pick up some stool collection kits. You tell Bill that, in addition to his regular inspection routine, you
want him to check for any water-related play activities, such as wading pools or water tables, the center might
offer during the summer. You tell Marge to give special attention to child care practices in the rooms where they
are diapering children and to disinfection practices.

Children using diapers are at greater risk for diarrhea than those who are toilet trained, because they explore their
environment and put things into their mouths more often than older children. The majority of children are toilet
trained by age 3 years. Outbreaks of diarrheal illness are less common among toilet-trained children and often
involve common exposure.

9. (1 point) Which of the below modes of transmission is most often involved in the transmission of
diarrheal diseases?(circle the best answer)
a. Direct.
b. Vectorborne.
c. Airborne.
d. Vehicleborne.

1
“Crypto” refers Cryptosporidium sp.
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You pull into the parking lot at Child Care Facility A, a large facility in what was once an elementary school. You
see a group of children playing with a water table and hose on the playground. Traffic was bad and you stopped
by the laboratory to pick up stool kits, so you are not surprised that Bill and Marge are already inside. You
introduce yourself to the receptionist and show her your identification badge. “Your colleagues are already going
about their business,” she says. “I’ll page Ms. Grey. Have a seat.” You look around as you wait. The halls are
clean, but with a faint odor of chlorine. Children’s art work, including drawings of handwashing and
toothbrushing, are displayed on the walls. A bulletin board has announcements of activities and a large poster
telling parents not to bring their children if they exhibit a list of symptoms.

Beth soon greets you. “Hi, I’m Beth Grey, the Director. You must be the person I spoke to on the phone. Thanks
for coming. Your colleagues are already checking the place out.” You explain that you would like to talk with her
to find out a little bit about the facility and the situation. She shows you to a small conference room just off the
main entrance.

She takes a seat and begins. “We’ve been here for almost seven years. We have 30 staff and a licensed capacity of
125 children. They don’t all come every day and we have about 150 enrolled right now. That includes our
afterschool kids. We don’t accept infants. We divide our kids up by age, 1-year-old, 2-years-old, 3-years-old, 4-
years-old, and then the 5-years-old. We have two classrooms for each. We call them A and B and name them by
the ages of the kids. Classroom 1A is one of the classrooms for our 1-year old kids. Classroom 1B is the other.
Our kids move up to the next class on their birthdays. Our normal hours are from 7:30 a.m. to 5:30 p.m., but we
have an early morning drop-off starting at 6:30 a.m. and a late-day group that ends at 6:30 p.m. We follow the
American Academy of Pediatrics recommendations for when kids should be kept home. We check our kids every
morning when they arrive. Our parents tell us when their kids are sick.”

Beth slides a piece of paper across the table toward you. “I had our receptionist reorganize the information you
wanted,” she says. Just then the receptionist comes to the door. “Ms. Grey, there is a call for you from Mrs.
Brownlee. She heard about an “epidemic” and wants to know more about it,” she says. Beth leaves to take the
call. You look at the information on the paper (Table 2) and compare the age distribution of children with diarrhea
during the last 2 years.

Table 2: Number of Children with Diarrhea* and Number of Children Present**

by Age Classroom for Weeks 29–36, 2012 and 2013

Year
2012 2013
Classroom No. Ill Child- No. Ill Child-
weeks weeks
1A 3 99 3 107
1B 2 89 5 91
2A 1 89 8 94
2B 2 73 4 70
3A 1 105 3 110
3B 2 109 4 111
4A 1 110 2 114
4B 0 134 3 136
5A 1 151 0 153
5B 0 141 0 138
*
Includes illness reported by parents and observed by care givers.
**
A child was counted as being present if he or she attended one whole day that week.

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10. (2 points) Which of the classrooms in Table 2 include children who are not toilet trained (assume all 3-
year-olds are toilet trained)?

11. (16 points [2 points] each) Complete the following table. Show calculations and units.

2012 2013 Relative Risk (2013 vs. 2012)

Diapered (Incidence Rate) A B C
Toilet-trained (Incidence Rate) D E F
Relative Risk: Diapered vs.
G H
Toilet-trained

A.
B.
C.
D.
E.
F.
G.
H.

12. (2 points) Which of the following statements are supported by the information in Table 2 and your
calculations? (circle all that apply)
a. Diapered children had greater risk for diarrheal illness than toilet-trained children during both
periods.
b. Both groups experienced greater risk for diarrheal illness during 2012 than 2013.
c. The excess risk among diapered children, compared with toilet-trained children was
significantly greater during 2013 than 2012.
d. The data support a hypothesis that the increase in diarrheal illness during 2013 involved both
diapered and toilet-trained children.
e. None of the above.

Beth returns a few minutes later. She tells you that Bill and Marge are nearly finished with their inspection. You
tell her you saw some interesting things in the information she provided. “I’ve spoken with the folks at the lab and
we think this might be caused by a parasite called Cryptosporidium, commonly called ‘Crypto.’ ” About that time
your cell phone buzzes. Your secretary is calling so you answer. “The lab just called,” she says. “They were able
to speed up testing and the stool from the day care child was positive for Crypto.” You thank her and turn to Beth.
“I think this problem might be Crypto,” you say. “I have some stool containers and parent permission forms in the
car. I’ve only got a dozen right now but I think it would be a good idea if we could collect some stool specimens
from some of your kids and get them tested for Crypto.” “Sure, we can set that up,” Beth says. “Who do you want
to test?”

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13. (2 points) You have 12 stool collection kits available and need to decide which children to test. Which of
the following screening schemes would be the best to use if you wanted to test the hypothesis that,
throughout the center, those with diarrhea have Cryptosporidium and those without diarrhea do not?
a. Select classrooms with the most ill children and test only those with a recent history of diarrhea.
b. Test only children with a recent history of diarrhea, but select only one or two from each
classroom.
c. Select one or two classrooms and test a few children with a recent history of diarrhea and a
group of children who have not had diarrhea (controls).
d. Test a randomly selected group of children with a recent history of diarrhea and a randomly
selected group of children without a recent history of diarrhea.

15. (1 point) If you were to randomly select a group of 12 children and test each of them even if they
haven’t had recent illness, would you be measuring incidence or prevalence of infection?

You know that noninfectious diarrhea is a fairly common occurrence in young children and decide to test ten
children with a recent history of diarrhea from different classrooms and two children who have not had diarrhea.

Bill and Marge come into the room as you finish explaining your testing plan to Beth. You ask her to leave the
room so you can hear their reports in private. “Okay, it looks like we have a Crypto outbreak here,” you say. “At
least the boy who was hospitalized this last weekend tested positive. What did you find?”

Marge speaks first. “Well, the children in the 1-year-old rooms were having their nap time so I did not get to see
much. I spent most of my time in the 2-year old rooms. They have two rooms for each age group and use dividers
to break the rooms up into smaller areas. The second was a real zoo. One of the children had an ‘accident.’ Feces
were running down the poor kid’s leg and the others were all screaming ‘poooeeeey,’ ‘stinkkeee,’ stuff like that at
him. Fortunately, he was on a tiled surface and the aides followed the accepted protocol while cleaning up the
mess. I was a bit concerned to see one of the aides wash the child’s backside off in the sink before diapering him.”

Marge continues. “The setup was pretty much the same with the 3-year-olds. They have a child-sized toilet in the
corner and a handwashing sink. The sink had a bunch of toys in it that were going to be washed in the dishwasher.
They were serving snacks in one of the rooms and the children were helping pass out cookies. I asked about
handwashing and the teachers told me that the servers were very careful and all used hand sanitizer.”

16. (4 points) List four of Marge’s observations that could have contributed to this outbreak.

Then Bill reports. “I checked the food service area. All meals are prepared offsite and delivered as individual
servings to the center daily. They are refrigerated until just before lunchtime, heated in a convection oven, and
brought to the classroom where they are served. Drinks are individual sealed servings, you know, the type where
you use a straw to punch a hole in a seal. The utensils and serving units are all disposable so there is very little
dishwashing needed. The receptionist does all the food preparation and heating. She says she never changes
diapers at the center. The refrigeration was working fine. The kitchen area was pretty clean, although I did tell
them they needed to change the fly strip, because it was getting crowded. All chemicals and cleaning materials
were stored correctly. I really did not find much to cause concern.”

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Bill continues, “The playground was in good shape. Equipment was all in good repair and more than the required
amount of shock-absorbent material under the swings and climbing equipment was available. The sandboxes all
had covers to keep the neighborhood cats out and they looked like they were in good repair. I did not see any
wading pools, but there were a couple water tables.2 One was being used when I was there. I asked about
handwashing. The teacher told me the children all used hand sanitizer before water play. I did see a couple of
children drinking the water. The teacher told me that the water tables are emptied out at the end of the day or
when the water gets dirty. They hose the tables out, turn them upside down, and let them air dry. The toys used in
the water tables are just allowed to air dry.”

17. (3 points) List three of Bill’s observations that are cause for concern in regard to this outbreak.

You tell Bill and Marge that you want to screen some of the children for Crypto. You discuss recommendations
with them, making sure they agree and that you have covered all points. Marge points out that the facility
currently allows children with diarrhea to attend as long as their diapers can contain the stool. After feces leaked
out, it is too late to do much other than clean up the mess. She suggests you recommend changes to the center’s
attendance policy.

18. (6 points) Which of the below recommendations would you make concerning this outbreak? (circle all
that apply)
a. (Answer) Exclude all children with diarrhea until their diarrhea is resolved. (1 point)
b. Screen all children and staff and allow only noninfected persons to enter the facility.
c. Screen all children, staff and household contacts and exclude all persons who were infected or were
household contacts of infected persons until they were no longer infected whether they had
diarrhea or not.
d. Implement a program of daily disinfection of floors, walls, ceilings and other environmental
surfaces throughout the building.
e. (Answer) Instruct staff in correct handwashing, diapering, and other hygiene activities, and monitor their
performance. (1 point)
f. (Answer) Exclude children with diarrhea from using water tables. (1 point)
g. Install hand sanitizer dispensers throughout the facility and encourage both children and staff to
use them rather than washing their hands.

After you talk with Bill and Marge, you call Beth into the room and go over your recommendations with her. You
write them down and ask to have them photocopied so you can leave a set with her. You arrange to pick up the
stool specimens in 2 days, agree to stay in touch, and leave to go back to your office.

Late Wednesday afternoon, you get a call from Larry at the state laboratory. He has received the stool specimens
from Child Care Facility A and should have results for you by the close of business on Thursday. He points out
that the test they use has a sensitivity of only 75% for single-stool specimens and that you might want to consider
getting multiple specimens from each child. You tell him you will consider that option and get back to him.

19. (4 points) The sensitivity of the laboratory test for Crypto is 75%, the specificity is 100%, and the true
prevalence of infection is 20%. If you screen 100 children, how many infections will you miss? (Show
your calculations.)

2
Water tables are wood or plastic tables with raised, 4–6-inch edges. They are filled with water or sand and young children
play in them with boats, cups, and other toys. Although children can splash and pour water on each other, usually only their
hands and arms get into the water.
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 (Answer) Five infections will be missed.
Sensitivity = 75% Sensitivity = TP/(TP + FN). (1 point)
Prevalence = 20% of 100 = 20 = TP + FN. (1 point)
.75 = TP ÷ 20
TP = .75 × 20 = 15
FN = 20 – 15 = 5 infections missed.

(Scoring guidance 1point for right formula for sensitivity, 1 point for correct use of prevalence, 1 point for putting
data in correctly, 1 point for correct answer)

20. (1 point) If you were to screen each child twice and consider a child to be infected if either specimen is
positive, would the sensitivity increase, decrease or remain the same?

(Answer) Sensitivity would increase. (1 point)

You call Beth at Child Care Facility A before you leave for the day and ask her how things are going. She says
multiple episodes of diarrhea in various classes throughout the facility have been reported, but the majority were
among children who were ill before. However, three children had diarrhea for the first time. Two are in the 3-
year-old group and one is in the 4-year-old group. The latter has a brother in the toddler class who was ill last
week. You tell her you should have results back on Thursday and you will visit Friday morning to discuss follow-
up activities.

At midafternoon on Thursday, one of your staff stops by your office to tell you that the laboratory put a rush on
testing your specimens and the results are ready. She combined the laboratory results with other information from
the children who were tested into a single table that she gives you to review (Table 3). She tells you the laboratory
has already contacted the pediatricians of each child tested. They will notify the parents of children who were
tested and give them the results. Confidentiality laws do not allow you to give this information directly to Beth,
but the parents were told they need to tell her about the results. After that is done, you can discuss the situation
with her.

Table 3: Results of Initial Screening for Cryptosporidium at Child Care Facility A

Result Classroom Week Onset Symptomatic

Positive 1A 35 Yes
Positive 1A 36 Yes
Positive 2A 36 Yes
Positive 3A 35 Yes
Positive 3A 36 Yes
Positive 4B 36 Yes
Negative 1B 36 Yes
Negative 2A 35 Yes
Negative 2B 36 Yes
Negative 4B 35 Yes
Negative 1A NA No
Negative 1A NA No

21. (2 points) Give two explanations for the four negative test results from children with symptoms.

(Answer) Their illness was caused by something other than Crypto. (1 point)
(Answer) An error in the test or collection was encountered. (1 point)
(Answer) They had recovered from illness by the time specimens were collected. (1 point)

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(Scoring guidance: accept any of the above or variants)

22. (4 points) Now that you have a good idea about the agent responsible for this outbreak, write a case
definition that you can use for the remainder of the investigation.

(Answer) — Definition should address each of the four following attributes.

• Clinical information about the disease, including a history of watery diarrhea. (1point)
• Information about the location or place, Child Care Facility A. (1 point)
• Characteristics about persons who are affected (e.g., staff or child). (1 point)
• A specification of time during which the outbreak occurred, during weeks 34–37, 2013. (1 point)

(Scoring guidance: accept positive test for Crypto instead of or with watery diarrhea; give 1 point extra if they
use this as confirmed versus suspect cases.)

You finish reviewing the results and call Beth. She says that several parents have already contacted her about the
children’s results. She is really concerned because they have had more children and staff with diarrhea during the
last week than in any previous week. The majority of classrooms have had at least one ill child. Certain parents
told Beth they were thinking of moving their children to another child care program, because they are concerned
that the problem is growing and everybody might eventually be infected. You ask Beth to send you names and
classrooms of the additional children with diarrhea and discuss a second round of testing with her. You also call
Larry to thank him for expediting the results. You discuss the possibility of testing all the children and staff who
have not been screened previously and send him an e-mail with a copy of the table. Larry says the laboratory can
handle the specimen load for testing everyone in the center, but it will take a day or so to get things together.

On Friday afternoon you call Beth and ask how things are going at the center. She sounds a bit dejected as she
tells you that they have done everything you recommended, but are winding up the week with more children with
diarrhea than they had the week before and not to mention that children who they thought had recovered are
getting diarrhea again. You explain to her that it can take a week or more for symptoms to develop after a person
has been infected with Cryptosporidium and certain newly ill persons were probably infected before the control
measures were put in place. You explain that recrudescence, or recurrent bouts of diarrhea, is common with
Crypto and that the best way to prevent additional cases is to adhere to the guidelines for preventing spread of
infection. You tell her you will come by Monday to set up testing for all children and staff.

First thing Monday morning you pick up the supplies needed to test everyone at Child Care Facility A. When you
arrive at the facility to drop off the supplies, you notice that things seem different than they did a week ago,
including, fewer children and less of a bleach odor. The water tables are gone from the playground and the
wastebasket next to the sink in one of the classrooms is full of used paper towels. When you mention these
observations to Beth, she says they are not using as much bleach and have switched to disinfecting with peroxide
until the outbreak ends. Staff also stopped using hand sanitizer and is having the children wash their hands with
soap and water when they arrive in the morning. She says they were going to follow your suggestions about
cleaning the water tables, but were concerned that children who were infected and did not have diarrhea would
contaminate them. “The weather is getting cooler anyway and we thought it best to just put them up,” she says.

Beth and another staff person help you unload the test supplies from your car. You go over the instructions and
make sure staff knows what to tell parents. After you review plans for picking up the samples, getting them to the
laboratory, and managing additional cases, you head off for a meeting with the infection control practitioners in
your area.
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On Friday you call Beth. She says sample collection is going well and they have had substantially fewer children
reporting diarrhea during the past week than the week before. Recurrence remains a problem, but the situation is
improving. You make it clear that the reduction is attributable to their improved hygiene practices, not to
screening.

Approximately 2 months have passed and you are piecing together data from the Child Care Facility A outbreak.
You compare results of the facility-wide testing with reports of watery diarrhea among children and staff (Table
4).

Table 4: Results of Facility-wide Screening (Test 2) for Cryptosporidium Among Children and Staff Who Were
Symptomatic (Reported Watery Diarrhea) or Asymptomatic

Screening Results
Symptomatic
Positive Negative
Yes 41 12

No 10 120

Total 51 132

23. (2 points) What was the attack rate of laboratory-confirmed Cryptosporidium infection among children
and staff at Child Care Facility A during weeks 32–40? (Show your calculations.)

24. (4 points) Using the laboratory test as the ultimate standard for identifying persons with
Cryptosporidium infections, what is the sensitivity of using watery diarrhea as an indicator? (Show
your calculations.)

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Figure 1: Number of Persons with Symptoms and Positive Results for Cryptosporidium Infection in Diapered and
Toilet-Trained Classrooms, by Week of Symptom Onset

10
Number of
8
persons
symptomatic and 6
with positive Diapered
results for 4 Toilet-trained
Cryptosporidium
2
infection
0
32 33 34 35 36 37 38 39 40

Week of onset

25. (2 points) What does the data in Figure 1 indicate about where the outbreak started and where it
ended?

(Answer) The outbreak appears to have started among the diapered children (1 point), and then spread to toilet-
trained children. (1 point)

26. (3 points) On the basis of what you have been told about practices and conditions in this child care
facility, list three ways that Cryptosporidium infection might have spread from one of the above groups
to the other.

(Answer) They shared the same water tables. (1 point)

(Answer) Transmission at home. (1 point)
(Answer) Transmission among early drop-off and late pick-up groups. (1 point)

(Scoring guidance: question addresses transmission between diapered and toilet-trained children, but not among
children in same age groups. Accept any reasonable answer. Examples given above.)

27. (2 points) How can you explain the fact that your prevention measures were started at the beginning of
week 37, yet the greatest number of cases in both diapered and toilet-trained persons occurred during
that week (i.e., were your measures effective or not)?

(Answer) Measures were effective. Crypto has a substantial incubation period and those who became ill during
week 37 were probably infected before prevention measures were implemented. (2 points)

28. (6 points) List three broad recommendations you would make for all child care programs in your area
to prevent this sort of outbreak from happening again.

(Answer) Educate staff and parents. (2 points)

(Answer) Exclude any child with diarrhea from the child care setting until the diarrhea has stopped. (2 points)
(Answer) Establish, implement, and enforce policies concerning water-play and swimming. (2 points)
(Answer) Practice good hygiene. (2 points)

13
(Answer) Reinforce the need for correct diapering practices. (2 points)
(Answer) Disinfect surfaces and objects, including but not limited to bathrooms, diaper-changing areas, food-
preparation areas, tabletops, high chairs, and toys. (2 points)
(Answer) Notify the state or local health department about an excessive level of diarrhea or any Crypto cases in
the child care facility. Crypto is a nationally reportable disease. (2 points)

(Scoring guidance: accept paraphrasing of any of the above recommendations or other reasonable ones.
Competitors can include more than three answers, but only score the first three.)

14
 2014 Division B

Part B: Fun at the Child Care Center

Key

It is a warm Monday morning in mid-September. You are the chief epidemiologist at a large city health
department. As you review reports electronically transmitted to your office during the weekend, the phone rings.
The caller is Beth Grey, director of Child Care Facility A, a child care center in your jurisdiction. Beth says she
received a call from the parents of a young boy who was hospitalized during the weekend with severe diarrhea
and dehydration. She says her staff has noticed a slight increase in the number of children with loose stools during
the last few weeks. The staff was not too concerned because the stools were not bloody, and pediatricians were
telling parents the diarrhea was because of teething, food allergies, or antibiotic use.

1. (1 point) Which of the following represents a key component of the definition of an outbreak? (circle
the best answer)
a. The outbreak happens suddenly.
b. The outbreak involves a numerous persons.
c. Certain persons are hospitalized or die.
d. (Answer) More cases than expected are reported. (1 point)
e. The outbreak is caused by an infectious agent.
f. The outbreak is widespread.

2. (1 point) Which of the below pieces of information would be most helpful to determine if this represents
an outbreak? (circle the best answer)
a. The causative agent.
b. The source of infection.
c. The index case,
d. (Answer) The number of children who had diarrhea during the same period last year. (1
point)
e. The number of secondary cases.
f. None of the above.

You ask Beth for the child’s name, age, hospital where he was admitted, his pediatrician’s name, whether she
knows of any laboratory results, and the last date the boy attended the center. Beth tells you the child is 3 years
old and is at Children’s Hospital under the care of Dr. Brown. She replies that she does not know what kind of
tests were done. The boy last attended the child care center on the previous Thursday and was well that day. You
have worked with Dr. Brown and know him to be an excellent physician who understands public health as well as
clinical medicine. However, you are concerned about the recent increase regarding children with diarrhea at Child
Care Facility A and need more information before you can develop a hypothesis.

3. (1 point) Which of the following is the most important question you would ask about the children with
diarrhea to understand place? (circle the best answer)
a. Where do they live?
b. (Answer) What classroom is each child in? (1 point)
c. Have they traveled out of the area?
d. What other exposures did they have in the week before they became ill?

4. (1 point) Which of the following is the most important question you would ask about the children with
diarrhea to understand time? (circle the best answer)
a. When was the last day they were at the center?
b. What time of day did they become ill?
c. When did they first attend the center?
15
 d. (Answer) What day did they become ill? (1 point)

You tell Beth that you have to get ready for a meeting. Before you end the call, you ask Beth to provide
information concerning the number of children with diarrhea at the child care center for the previous 8 weeks of
this year and the same period last year. For each week, you need the number of children with diarrhea and the
number who attended at least one day during that week. Beth says she will have someone get right on it and send
the information to you in a spreadsheet by e-mail. When your meeting is over, you check your e-mail and find
Table 1 from Beth.

Table 1: Number of Children with Diarrhea* and Number of Children Present** at Child Care Facility A, by
Weeks 29–36, 2012 and 2013***

Week Week Week Week Week Week Week Week Total

29 30 31 32 33 34 35 36
2012
No. with 1 0 3 2 0 4 1 2 13
Diarrhea
No. Present 134 143 138 132 139 141 137 136 1100
2013
No. with 2 1 3 1 1 3 7 14 32
Diarrhea
No. Present 142 139 137 141 143 138 144 140 1124
*
Includes those recorded by child care providers and reported by parents during daily health checks.
**
A child was considered present if he or she attended at least one whole day during the week.
***
Health department was notified at start of week 37.

5. (3 points) Calculate the incidence of diarrhea per 100 child-weeks during weeks 29–36 in 2013. (Hint:
The number of child weeks is the same as the number of children present each week)

(Answer) Incidence 2013 = (32) ÷ 1124 X 100 = 2.85 cases per 100 child-weeks. (3 points)
.

(Scoring guidance: 1 point for correct numerator, 1 point for correct denominator, 1 point for correct
rate.)

6. (2 points) Determine the relative risk (RR) for diarrhea during 2013, compared with 2012.

(Answer) RR = Incidence 2013 ÷ Incidence 2012 = 2.85 ÷ 1.18 = 2.41.

(Note: Incidence 2012 = (13) ÷ 1100 X 100 = 1.18 cases per 100 child-weeks)

You review the data in Table 1, call Dr. Brown’s office, and ask his nurse about the boy admitted to Children’s
Hospital. She says the child was admitted for acute dehydration resulting from watery diarrhea and vomiting. He
responded well to treatment and was sent home a few hours ago. A stool sample was collected when the child was
admitted Sunday and test results should be available within a day or so. The initial diagnosis was viral diarrhea or
possible cryptosporidiosis — definitely not related to teething or antibiotics. You thank her for the information.
You ask whether the hospital lab can speed up the testing and call you as soon as they get results. The nurse says
she will do her best.

16
You call Beth to tell her that on the basis of the information she sent, a problem might have developed. She says
they have had a terrible day so far. One of her teachers went home ill and at least three more children developed
diarrhea. In one of the 4-year-old classrooms, a child had feces running down her leg. She says one child had the
same symptoms the week before last, got better, and is sick again. You tell her that you spoke with Dr. Brown’s
office and it appears a communicable disease outbreak at the center might be occurring, and you will put together
a team to visit this afternoon. You ask Beth to break down the data she sent by classroom and create a table
showing the number of children with diarrhea and number of child-weeks of attendance for each classroom 8-
week period. You explain to her how to calculate child-weeks of attendance.

7. (1 point) Which part of the descriptive epidemiology triad are you addressing by looking at the data by
classroom?

(Answer) Place. (1 point)

(Scoring guidance: also accept Person, because classroom and age are linked.)

You contact the Environmental Health and Nursing units of the health department, explain the situation, and ask
them to assign a sanitarian and public health nurse to accompany you on a field visit. You next contact the local
office of the child care licensing agency to let them know what is going on and what you plan to do, and invite
them to send a representative along on the field visit. Finally, you call your colleague Larry Johnson at the state
laboratory and talk with him about the situation. “You know, Dr. Brown may well be right on this one,” Larry
says. “Several types of viruses cause watery diarrhea. Rotaviruses and noroviruses are the most common. A
vaccine is available for rotavirus, and norovirus outbreaks tend to be really explosive. This outbreak seems a bit
like a slow burner. That kid who was sick, got well, and then is sick again sure sounds like a recrudescent case.
We see that a lot with Crypto 3. Why don’t you stop by and pick up some stool collection kits? We can test for that
here.”

8. (2 points) List two steps of an outbreak investigation that were addressed in the previous paragraph.

(Answer) Prepare for fieldwork. (1 point)

(Answer) Verify the diagnosis. (1 point)

You tell your secretary that you will probably be at Child Care Facility A all afternoon. You meet Bill Rosales,
the sanitarian, and Marge Kunith, the public health nurse, in the parking lot and give them the address. You tell
them a colleague at the state laboratory thinks this might be a cryptosporidiosis (Crypto) outbreak and you are
going to pick up some stool collection kits. You tell Bill that, in addition to his regular inspection routine, you
want him to check for any water-related play activities, such as wading pools or water tables, the center might
offer during the summer. You tell Marge to give special attention to child care practices in the rooms where they
are diapering children and to disinfection practices.

Children using diapers are at greater risk for diarrhea than those who are toilet trained, because they explore their
environment and put things into their mouths more often than older children. The majority of children are toilet
trained by age 3 years. Outbreaks of diarrheal illness are less common among toilet-trained children and often
involve common exposure.

9. (1 point) Which of the below modes of transmission is most often involved in the transmission of
diarrheal diseases?(circle the best answer)
a. Direct.
b. Vectorborne.
c. Airborne.
d. (Answer) Vehicleborne. (1 point)

3
“Crypto” refers Cryptosporidium sp.
17
You pull into the parking lot at Child Care Facility A, a large facility in what was once an elementary school. You
see a group of children playing with a water table and hose on the playground. Traffic was bad and you stopped
by the laboratory to pick up stool kits, so you are not surprised that Bill and Marge are already inside. You
introduce yourself to the receptionist and show her your identification badge. “Your colleagues are already going
about their business,” she says. “I’ll page Ms. Grey. Have a seat.” You look around as you wait. The halls are
clean, but with a faint odor of chlorine. Children’s art work, including drawings of handwashing and
toothbrushing, are displayed on the walls. A bulletin board has announcements of activities and a large poster
telling parents not to bring their children if they exhibit a list of symptoms.

Beth soon greets you. “Hi, I’m Beth Grey, the Director. You must be the person I spoke to on the phone. Thanks
for coming. Your colleagues are already checking the place out.” You explain that you would like to talk with her
to find out a little bit about the facility and the situation. She shows you to a small conference room just off the
main entrance.

She takes a seat and begins. “We’ve been here for almost seven years. We have 30 staff and a licensed capacity of
125 children. They don’t all come every day and we have about 150 enrolled right now. That includes our
afterschool kids. We don’t accept infants. We divide our kids up by age, 1-year-old, 2-years-old, 3-years-old, 4-
years-old, and then the 5-years-old. We have two classrooms for each. We call them A and B and name them by
the ages of the kids. Classroom 1A is one of the classrooms for our 1-year old kids. Classroom 1B is the other.
Our kids move up to the next class on their birthdays. Our normal hours are from 7:30 a.m. to 5:30 p.m., but we
have an early morning drop-off starting at 6:30 a.m. and a late-day group that ends at 6:30 p.m. We follow the
American Academy of Pediatrics recommendations for when kids should be kept home. We check our kids every
morning when they arrive. Our parents tell us when their kids are sick.”

Beth slides a piece of paper across the table toward you. “I had our receptionist reorganize the information you
wanted,” she says. Just then the receptionist comes to the door. “Ms. Grey, there is a call for you from Mrs.
Brownlee. She heard about an “epidemic” and wants to know more about it,” she says. Beth leaves to take the
call. You look at the information on the paper (Table 2) and compare the age distribution of children with diarrhea
during the last 2 years.

Table 2: Number of Children with Diarrhea* and Number of Children Present**

by Age Classroom for Weeks 29–36, 2012 and 2013

Year
2012 2013
Classroom No. Ill Child- No. Ill Child-
weeks weeks
1A 3 99 3 107
1B 2 89 5 91
2A 1 89 8 94
2B 2 73 4 70
3A 1 105 3 110
3B 2 109 4 111
4A 1 110 2 114
4B 0 134 3 136
5A 1 151 0 153
5B 0 141 0 138
*
Includes illness reported by parents and observed by care givers.
**
A child was counted as being present if he or she attended one whole day that week.

10. (2 points) Which of the classrooms in Table 2 include children who are not toilet trained (assume all 3-
year-olds are toilet trained)?
18
(Answer) 1A and 1B. (1 point each)
(Answer) 2A and 2B. (1 point each)

11. (16 points [2 points] each) Complete the following table. Show calculations and units.

2012 2013 Relative Risk (2013 vs. 2012)

Diapered (Incidence Rate) A B C
Toilet-trained (Incidence Rate) D E F
Relative Risk: Diapered vs.
G H
Toilet-trained

A. I diapered 2012 = 8 ill children ÷ 250 child-weeks = 0.023 ill children/child-week

B. I diapered 2013 = 20 ill children ÷ 362 child-weeks = 0.06 ill children/child-week
C. RR diapered 2013 ÷ diapered 2012 = I diapered 2013 ÷ I diapered 2012 = 0.06 ÷ 0.023 = 2.42
D. I toilet trained 2012 = 5 ill children ÷ 750 child-weeks = 0.0067 ill children/child-week
E. I toilet trained 2013 = 12 ill children ÷ 762 child-weeks = 0.0157 ill children/child-week
F. RR toilet-trained 2013/toilet trained 2012 = I toilet trained 2013 ÷ I toilet trained 2012 = 0.0157 ÷ 0.0067 = 2.36
G. RR diapered 2012/ toilet trained 2012 = I diapered 2012 ÷ I toilet trained 2012 = 0.023 ÷ 0.0067 = 3.43
H. RR diapered 2013/ toilet trained 2013 = I diapered 2013 ÷ I toilet trained 2013 = 0.06 ÷ 0.0157 = 3.82

(Scoring guidance: give 1 point for plugging in right cells and 1 point for right answer.)

12. (2 points) Which of the following statements are supported by the information in Table 2 and your
calculations? (circle all that apply)
f. (Answer) Diapered children had greater risk for diarrheal illness than toilet-trained children
during both periods. (1 point)
g. Both groups experienced greater risk for diarrheal illness during 2012 than 2013.
h. The excess risk among diapered children, compared with toilet-trained children was
significantly greater during 2013 than 2012.
i. (Answer) The data support a hypothesis that the increase in diarrheal illness during 2013
involved both diapered and toilet-trained children. (1 point)
j. None of the above.

Beth returns a few minutes later. She tells you that Bill and Marge are nearly finished with their inspection. You
tell her you saw some interesting things in the information she provided. “I’ve spoken with the folks at the lab and
we think this might be caused by a parasite called Cryptosporidium, commonly called ‘Crypto.’ ” About that time
your cell phone buzzes. Your secretary is calling so you answer. “The lab just called,” she says. “They were able
to speed up testing and the stool from the day care child was positive for Crypto.” You thank her and turn to Beth.
“I think this problem might be Crypto,” you say. “I have some stool containers and parent permission forms in the
car. I’ve only got a dozen right now but I think it would be a good idea if we could collect some stool specimens
from some of your kids and get them tested for Crypto.” “Sure, we can set that up,” Beth says. “Who do you want
to test?”

13. (2 points) You have 12 stool collection kits available and need to decide which children to test. Which of
the following screening schemes would be the best to use if you wanted to test the hypothesis that,
throughout the center, those with diarrhea have Cryptosporidium and those without diarrhea do not?
e. Select classrooms with the most ill children and test only those with a recent history of diarrhea.
19
 f. Test only children with a recent history of diarrhea, but select only one or two from each
classroom.
g. Select one or two classrooms and test a few children with a recent history of diarrhea and a
group of children who have not had diarrhea (controls).
h. (Answer) Test a randomly selected group of children with a recent history of diarrhea and a
randomly selected group of children without a recent history of diarrhea. (1 point)

22. (1 point) If you were to randomly select a group of 12 children and test each of them even if they
haven’t had recent illness, would you be measuring incidence or prevalence of infection?

(Answer) Prevalence. (1 point)

You know that noninfectious diarrhea is a fairly common occurrence in young children and decide to test ten
children with a recent history of diarrhea from different classrooms and two children who have not had diarrhea.

Bill and Marge come into the room as you finish explaining your testing plan to Beth. You ask her to leave the
room so you can hear their reports in private. “Okay, it looks like we have a Crypto outbreak here,” you say. “At
least the boy who was hospitalized this last weekend tested positive. What did you find?”

Marge speaks first. “Well, the children in the 1-year-old rooms were having their nap time so I did not get to see
much. I spent most of my time in the 2-year old rooms. They have two rooms for each age group and use dividers
to break the rooms up into smaller areas. The second was a real zoo. One of the children had an ‘accident.’ Feces
were running down the poor kid’s leg and the others were all screaming ‘poooeeeey,’ ‘stinkkeee,’ stuff like that at
him. Fortunately, he was on a tiled surface and the aides followed the accepted protocol while cleaning up the
mess. I was a bit concerned to see one of the aides wash the child’s backside off in the sink before diapering him.”

Marge continues. “The setup was pretty much the same with the 3-year-olds. They have a child-sized toilet in the
corner and a handwashing sink. The sink had a bunch of toys in it that were going to be washed in the dishwasher.
They were serving snacks in one of the rooms and the children were helping pass out cookies. I asked about
handwashing and the teachers told me that the servers were very careful and all used hand sanitizer.”

23. (4 points) List four of Marge’s observations that could have contributed to this outbreak.

(Answer) One of the aids had washed the kid’s backside off in the sink before diapering him. (1 point)
(Answer) The sink had a bunch of toys in it. (1 point)
(Answer) The kids were helping to pass out cookies. (1 point)
(Answer) Servers were very careful and all used hand sanitizer. (1 point)

Then Bill reports. “I checked the food service area. All meals are prepared offsite and delivered as individual
servings to the center daily. They are refrigerated until just before lunchtime, heated in a convection oven, and
brought to the classroom where they are served. Drinks are individual sealed servings, you know, the type where
you use a straw to punch a hole in a seal. The utensils and serving units are all disposable so there is very little
dishwashing needed. The receptionist does all the food preparation and heating. She says she never changes
diapers at the center. The refrigeration was working fine. The kitchen area was pretty clean, although I did tell
them they needed to change the fly strip, because it was getting crowded. All chemicals and cleaning materials
were stored correctly. I really did not find much to cause concern.”

Bill continues, “The playground was in good shape. Equipment was all in good repair and more than the required
amount of shock-absorbent material under the swings and climbing equipment was available. The sandboxes all
had covers to keep the neighborhood cats out and they looked like they were in good repair. I did not see any

20
wading pools, but there were a couple water tables.4 One was being used when I was there. I asked about
handwashing. The teacher told me the children all used hand sanitizer before water play. I did see a couple of
children drinking the water. The teacher told me that the water tables are emptied out at the end of the day or
when the water gets dirty. They hose the tables out, turn them upside down, and let them air dry. The toys used in
the water tables are just allowed to air dry.”

24. (3 points) List three of Bill’s observations that are cause for concern in regard to this outbreak.

(Answer) All children used hand sanitizer before water play. (1 point)
(Answer) He observed a couple of the kids drinking the water. (1 point)
(Answer) Water tables are emptied out at the end of the day. (1 point)
(Answer) Staff hose water tables, turn them upside down, and let them air dry. (1 point)
(Answer) Toys used in the water tables are just allowed to air dry. (1 point)

(Scoring guidance: any three of the above)

You tell Bill and Marge that you want to screen some of the children for Crypto. You discuss recommendations
with them, making sure they agree and that you have covered all points. Marge points out that the facility
currently allows children with diarrhea to attend as long as their diapers can contain the stool. After feces leaked
out, it is too late to do much other than clean up the mess. She suggests you recommend changes to the center’s
attendance policy.

25. (6 points) Which of the below recommendations would you make concerning this outbreak? (circle all
that apply)
h. (Answer) Exclude all children with diarrhea until their diarrhea is resolved. (1 point)
i. Screen all children and staff and allow only noninfected persons to enter the facility.
j. Screen all children, staff and household contacts and exclude all persons who were infected or were
household contacts of infected persons until they were no longer infected whether they had
diarrhea or not.
k. Implement a program of daily disinfection of floors, walls, ceilings and other environmental
surfaces throughout the building.
l. (Answer) Instruct staff in correct handwashing, diapering, and other hygiene activities, and
monitor their performance. (1 point)
m. (Answer) Exclude children with diarrhea from using water tables. (1 point)
n. Install hand sanitizer dispensers throughout the facility and encourage both children and staff to
use them rather than washing their hands.

After you talk with Bill and Marge, you call Beth into the room and go over your recommendations with her. You
write them down and ask to have them photocopied so you can leave a set with her. You arrange to pick up the
stool specimens in 2 days, agree to stay in touch, and leave to go back to your office.

Late Wednesday afternoon, you get a call from Larry at the state laboratory. He has received the stool specimens
from Child Care Facility A and should have results for you by the close of business on Thursday. He points out

4
Water tables are wood or plastic tables with raised, 4–6-inch edges. They are filled with water or sand and young children
play in them with boats, cups, and other toys. Although children can splash and pour water on each other, usually only their
hands and arms get into the water.
21
 that the test they use has a sensitivity of only 75% for single-stool specimens and that you might want to consider
getting multiple specimens from each child. You tell him you will consider that option and get back to him.

26. (4 points) The sensitivity of the laboratory test for Crypto is 75%, the specificity is 100%, and the true
prevalence of infection is 20%. If you screen 100 children, how many infections will you miss? (Show
your calculations.)

(Answer) Five infections will be missed.

Sensitivity = 75% Sensitivity = TP/(TP + FN). (1 point)
Prevalence = 20% of 100 = 20 = TP + FN. (1 point)
.75 = TP ÷ 20
TP = .75 × 20 = 15
FN = 20 – 15 = 5 infections missed.

(Scoring guidance 1point for right formula for sensitivity, 1 point for correct use of prevalence, 1 point
for putting data in correctly, 1 point for correct answer)

27. (1 point) If you were to screen each child twice and consider a child to be infected if either specimen is
positive, would the sensitivity increase, decrease or remain the same?

(Answer) Sensitivity would increase. (1 point)

You call Beth at Child Care Facility A before you leave for the day and ask her how things are going. She says
multiple episodes of diarrhea in various classes throughout the facility have been reported, but the majority were
among children who were ill before. However, three children had diarrhea for the first time. Two are in the 3-
year-old group and one is in the 4-year-old group. The latter has a brother in the toddler class who was ill last
week. You tell her you should have results back on Thursday and you will visit Friday morning to discuss follow-
up activities.

At midafternoon on Thursday, one of your staff stops by your office to tell you that the laboratory put a rush on
testing your specimens and the results are ready. She combined the laboratory results with other information from
the children who were tested into a single table that she gives you to review (Table 3). She tells you the laboratory
has already contacted the pediatricians of each child tested. They will notify the parents of children who were
tested and give them the results. Confidentiality laws do not allow you to give this information directly to Beth,
but the parents were told they need to tell her about the results. After that is done, you can discuss the situation
with her.

Table 3: Results of Initial Screening for Cryptosporidium at Child Care Facility A

Result Classroom Week Onset Symptomatic

Positive 1A 35 Yes
Positive 1A 36 Yes
Positive 2A 36 Yes
Positive 3A 35 Yes
Positive 3A 36 Yes
Positive 4B 36 Yes
Negative 1B 36 Yes
Negative 2A 35 Yes
Negative 2B 36 Yes
Negative 4B 35 Yes
Negative 1A NA No
Negative 1A NA No

22
28. (2 points) Give two explanations for the four negative test results from children with symptoms.

(Answer) Their illness was caused by something other than Crypto. (1 point)
(Answer) An error in the test or collection was encountered. (1 point)
(Answer) They had recovered from illness by the time specimens were collected. (1 point)

(Scoring guidance: accept any of the above or variants)

28. (4 points) Now that you have a good idea about the agent responsible for this outbreak, write a case
definition that you can use for the remainder of the investigation.

(Answer) — Definition should address each of the four following attributes.

• Clinical information about the disease, including a history of watery diarrhea. (1point)
• Information about the location or place, Child Care Facility A. (1 point)
• Characteristics about persons who are affected (e.g., staff or child). (1 point)
• A specification of time during which the outbreak occurred, during weeks 34–37, 2013. (1 point)

(Scoring guidance: accept positive test for Crypto instead of or with watery diarrhea; give 1 point extra if
they use this as confirmed versus suspect cases.)

You finish reviewing the results and call Beth. She says that several parents have already contacted her about the
children’s results. She is really concerned because they have had more children and staff with diarrhea during the
last week than in any previous week. The majority of classrooms have had at least one ill child. Certain parents
told Beth they were thinking of moving their children to another child care program, because they are concerned
that the problem is growing and everybody might eventually be infected. You ask Beth to send you names and
classrooms of the additional children with diarrhea and discuss a second round of testing with her. You also call
Larry to thank him for expediting the results. You discuss the possibility of testing all the children and staff who
have not been screened previously and send him an e-mail with a copy of the table. Larry says the laboratory can
handle the specimen load for testing everyone in the center, but it will take a day or so to get things together.

On Friday afternoon you call Beth and ask how things are going at the center. She sounds a bit dejected as she
tells you that they have done everything you recommended, but are winding up the week with more children with
diarrhea than they had the week before and not to mention that children who they thought had recovered are
getting diarrhea again. You explain to her that it can take a week or more for symptoms to develop after a person
has been infected with Cryptosporidium and certain newly ill persons were probably infected before the control
measures were put in place. You explain that recrudescence, or recurrent bouts of diarrhea, is common with
Crypto and that the best way to prevent additional cases is to adhere to the guidelines for preventing spread of
infection. You tell her you will come by Monday to set up testing for all children and staff.

First thing Monday morning you pick up the supplies needed to test everyone at Child Care Facility A. When you
arrive at the facility to drop off the supplies, you notice that things seem different than they did a week ago,
including, fewer children and less of a bleach odor. The water tables are gone from the playground and the
wastebasket next to the sink in one of the classrooms is full of used paper towels. When you mention these
observations to Beth, she says they are not using as much bleach and have switched to disinfecting with peroxide
until the outbreak ends. Staff also stopped using hand sanitizer and is having the children wash their hands with
soap and water when they arrive in the morning. She says they were going to follow your suggestions about

23
cleaning the water tables, but were concerned that children who were infected and did not have diarrhea would
contaminate them. “The weather is getting cooler anyway and we thought it best to just put them up,” she says.

Beth and another staff person help you unload the test supplies from your car. You go over the instructions and
make sure staff knows what to tell parents. After you review plans for picking up the samples, getting them to the
laboratory, and managing additional cases, you head off for a meeting with the infection control practitioners in
your area.

On Friday you call Beth. She says sample collection is going well and they have had substantially fewer children
reporting diarrhea during the past week than the week before. Recurrence remains a problem, but the situation is
improving. You make it clear that the reduction is attributable to their improved hygiene practices, not to
screening.

Approximately 2 months have passed and you are piecing together data from the Child Care Facility A outbreak.
You compare results of the facility-wide testing with reports of watery diarrhea among children and staff (Table
4).

Table 4: Results of Facility-wide Screening (Test 2) for Cryptosporidium Among Children and Staff Who Were
Symptomatic (Reported Watery Diarrhea) or Asymptomatic

Screening Results
Symptomatic
Positive Negative
Yes 41 12

No 10 120

Total 51 132

29. (2 points) What was the attack rate of laboratory-confirmed Cryptosporidium infection among children
and staff at Child Care Facility A during weeks 32–40? (Show your calculations.)

(Answer) Prevalence = Number of cases ÷ Total population = 51 ÷ 183 = 27.9%. (2 points)

(Scoring guidance: give 1 point for formula and 1 point for correct calculation.)

30. (4 points) Using the laboratory test as the ultimate standard for identifying persons with
Cryptosporidium infections, what is the sensitivity of using watery diarrhea as an indicator? (Show
your calculations.)

Sensitivity = TP ÷ (TP + FN) = 41 ÷ (41 + 10) = 80.4% (4 points)

(Scoring guidance: give 1 point for formula, 2 points for using, correct numbers, and 1 point for correct
calculation)

24
You create a histogram showing the number of persons who were both symptomatic and whose stool test results
were positive for Cryptosporidium infection in diapered and toilet-trained classes (Figure 1).

Figure 1: Number of Persons with Symptoms and Positive Results for Cryptosporidium Infection in Diapered and
Toilet-Trained Classrooms, by Week of Symptom Onset

10
Number of
8
persons
symptomatic and 6
with positive Diapered
results for 4 Toilet-trained
Cryptosporidium
2
infection
0
32 33 34 35 36 37 38 39 40

Week of onset

31. (2 points) What does the data in Figure 1 indicate about where the outbreak started and where it
ended?

(Answer) The outbreak appears to have started among the diapered children (1 point), and then spread
to toilet-trained children. (1 point)

32. (3 points) On the basis of what you have been told about practices and conditions in this child care
facility, list three ways that Cryptosporidium infection might have spread from one of the above groups
to the other.

(Answer) They shared the same water tables. (1 point)

(Answer) Transmission at home. (1 point)
(Answer) Transmission among early drop-off and late pick-up groups. (1 point)

(Scoring guidance: question addresses transmission between diapered and toilet-trained children, but
not among children in same age groups. Accept any reasonable answer. Examples given above.)

33. (2 points) How can you explain the fact that your prevention measures were started at the beginning of
week 37, yet the greatest number of cases in both diapered and toilet-trained persons occurred during
that week (i.e., were your measures effective or not)?

(Answer) Measures were effective. Crypto has a substantial incubation period and those who became
ill during week 37 were probably infected before prevention measures were implemented. (2 points)
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29. (6 points) List three broad recommendations you would make for all child care programs in your area
to prevent this sort of outbreak from happening again.

(Answer) Educate staff and parents. (2 points)

(Answer) Exclude any child with diarrhea from the child care setting until the diarrhea has stopped. (2
points)
(Answer) Establish, implement, and enforce policies concerning water-play and swimming. (2 points)
(Answer) Practice good hygiene. (2 points)
(Answer) Reinforce the need for correct diapering practices. (2 points)
(Answer) Disinfect surfaces and objects, including but not limited to bathrooms, diaper-changing areas,
food-preparation areas, tabletops, high chairs, and toys. (2 points)
(Answer) Notify the state or local health department about an excessive level of diarrhea or any Crypto
cases in the child care facility. Crypto is a nationally reportable disease. (2 points)

(Scoring guidance: accept paraphrasing of any of the above recommendations or other reasonable
ones. Competitors can include more than three answers, but only score the first three.)

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