Professional Documents
Culture Documents
ABNGBE
ABNGBE
DEPARTMENT OF BIOSTATISTICS
Group members:
1 NEGASH NIGUS
2 ABDULMENAN MOHAMMED
3 BEZANESH MELESE
A 12-year old boy presented with difficulty in breathing, cough and hemoptysis
of 10 days duration. The problem started suddenly while he was bathing in small river
at Muger (110 kms.Northwest of Addis Ababa). He was seen in a nearby clinic and
was referred to Tikur Anbessa Hospital when his condition worsened. Examination
on arrival revealed a restless boy with a respiratory rate of 60/min, pulse rate of
130/min, but no fever. He had audible inspiratory stridor with intercostal and sub-
costal retractions and air entry was markedly diminished over both lung fields. There
was non-clotting trickle of blood in the mouth. The boy was immediately taken to the
operation theatre and was given 100% oxygen by mask. Direct laryngoscopy was
performed under general anesthesia using ketamine, atropine and succinic choline
after oxygenation. A leech was seen about 0.5 cm distal to the vocal cords and was
extracted using biopsy forceps; it was alive and measured 5 cm in length. The child
1
improved markedly after the procedure and was discharged symptom free the next
day. What study design was used in this report? Why?
Answer: the study is a descriptive case report study design.
Because the report is telling us the experience and the health profile of a single patient
including the definition of the disease, when the disease is occurred, where the person
live(the patient) and personal characteristics of the patient, so the design used is a
case report study design.
In a hospital there were about 120 patients having diseases in the same degree.
These patients were divided into three groups and three different drugs were given
for each group to test the effectiveness of the drugs. The assignment of patients to
each treatment arm was random. The outcome variable is global assessment of
function (GAF). High score means better functioning and the observations vary from
0 to 100. What type of study design was used? Why?
2
Because the intervention taken was treatment based on drugs and the treatments are
used as an exposure and better functioning is the outcome of interest, also the study
participants were persons with disease.
Used to test the effectiveness of the drugs, so by all of this things the study is a
randomized clinical trial.
3
size. If you have a large enough sample size, almost anything can be found to be
statistically significant.
Clinical significance: the practical importance of the treatment effect whether it has
a real, noticeable effect on daily life. If the treatment makes a positive and noticeable
improvement on a patient it is clinically significant or important.
It is sometimes called clinical importance or practical importance. There is no an
“official” or gold standard definition of clinical significance because the criteria will
change depending on the disease, condition, or patient population.
It is a subjective interpretation of a research result as practical or meaningful for the
patient and thus likely to affect provider behavior, this term is generally accepted as
the practical significance of the research or how meaningful the results would be to
the patient? For example, will you change your prescribing behavior or treatment of
certain patient populations as a result of the research findings?
Suppose a new test named “Test X" is developed for screening of cervical
cancer. This new test was applied on 500 known early cases of cervical cancer and
4
550 women without cervical cancer. The test was positive for 450 women with
cervical cancer and 30 women without cervical cancer.
A. Show the results by 2X2 table
B. How do you determine the validity of Test X? Calculate and interpret the measures
of validity.
C How do you determine the predictive value of Test X? Calculate and interpret the
predictive value of Test X.
5
Answer: for A,
Test Results Disease status
Answer for B,
Validity is the extent to which data collected actually reflect the truth. The concepts
of sensitivity (ability to detect true positive) and specificity (ability to detect true
negatives) can be used to characterize the validity of a measure ("measurement
validity").
The measures of validity are:
6
Sensitivity: the proportion of people with a disease who have a positive test for the
disease.
Sensitivity = a/(a+c) =400/(450+50)=0.9=90%
Interpretation: 90% of the women with cervical cancer correctly identified as
diseased (test positive).
But, 10% of women who had cervical cancer classified as free diseased (false
negative)
Specificity: is the proportion of people without the disease who have a negative test
Specificity= d/(b+d)=520/(30+520)=0.95=95%
Interpretation: 95% women without cervical cancer (disease) identified
Correctly (true negative).
But, 5% women who did not have cervical cancer classified (false positive).
Answer for C,
7
Predictive value is the ability of a test to predict the presence or absence of
disease from test results. And Predictive value of a test is determined by
Sensitivity, Specificity and the Prevalence of the disease.
Positive predictive value: is the probability of the presence of the disease in a person
with a positive test result.
𝑎 450
(+PV = = =0.94=94%
𝑎+𝑏 450+30
Interpretation: 94% of the women with positive test result really have the disease.
Negative predictive value: is the probability of not having the disease when the test
result is negative.
𝑑 520
(-PV = = =0.91=91%
𝑐+𝑑 50+520
Interpretation: 91% of the women with negative test result really have no cervical
cancer
8
Cohort study was conduct to identify the risk of death among patients with
heart attack who are smoker and nonsmoker. The result of the study was given by
table below.
Heart attack Smoker Quit Total
patients
Death 27 14 41
Survival 48 67 115
Total 75 81 156
A. Calculate OR/RR.
9
B. Interpret the result of OR/ RR.
Interpretation: patients who smoked had 1.57 times higher risk of death with heart
attack when compared to non-smokers.
C. Construct 95%CI for OR/ RR. The 95% confidence interval for log (RR)
c/(c+d)= 48/(48+67)=0.42
√14/27*41+67/48*115) =0.158
=(-0.115,0.505)
10
Thus, a 95% confidence interval for the true RR is obtained by exponentiation the
interval for log (RR):
There were 6000 deaths (1200 leukemia, 1750 stroke, 250 pneumonia, 250
Hodgkin’s disease, and 2500 acute myocardial infarction) in Cook County, which had
a population of 2.5 million in 1991.
A. Compute the cause specific death rare for acute myocardial infraction
Cause specific death rate (CSDR) =
number of death due to acute myocardial infection 2500
*10^n= *100,000=100 acute myocardial
total population of period 2500000
11
B. Compute the proportionate mortality rate for leukemia
death due to leukemia
Proportionate mortality rate= *100
death from all cases
1200
= *100=20%
6000
So, the proportionate mortality rate causes by leukemia is 20% out of 6000 number
deaths.
An ecological study Uses data from entire population to compare disease frequencies
between different groups during the same period of time, or in the same population
at different points in time.
12
A large number of epidemiologic, evolutionary, and clinical studies have confirmed
that salt intake is an important factor in elevating the blood pressure in human.
Let us consider two different group of populations with high and low salt intake:
To determine the association between the salt intake and hypertension we can
perform the following measures for both populations of interest in the same time and
have to follow ecological investigation through steps.
Measures:
13
and low amount of the urinary excretion of sodium in which high
level of the mean of both systolic BP and diastolic BP implies the
higher hypertension.
For example, let us define source of population as the two study groups coming from
the same source population. This would allow us to compare incidence of
14
hypertension in the two groups. Imagine Population A (those who use high amount
of salt) and population B (those who do not use high amount of salt)
Step 2: Formulate hypothesis the ecological study relates group (or aggregate)
characteristics to rates in each group.
We use ecological study design, because we need data at the population level
rather than the individual level.
Step 4: Data Collection With our hypothesis and source population defined, we now
need to determine where we will get the necessary data. Ecological studies involve
comparison and analysis of variables at the population level.
15
We will need to know the number of new cases of hypertension as well as their
addresses.
Additionally, we need to know the population size of these areas and the amount
of salt used during a given time period
16
Step 6: Drawing conclusion using the ecological study design, we can only draw
conclusions concerning the groups or populations under analysis. We cannot draw
conclusions about the individual members of the population because we do not have
exposure and outcome data on each member.
Example
A study in Yi (an ethnic minority living in southwestern china) farmers who lived in
a remote mountainous environment and consumed a sodium-poor a BP rose very little
with increasing age (0.13 and 0.23mmHg/year for systolic and diastolic respectively).
In contrast a Yi migrants and Han people who lived in urban areas consumed a
sodium-rich diet and experienced a much greater in BP with progressive aging (0.33
and 0.33mmHg/year for systolic and diastolic respectively).
Another study in Kenya showed that a migrants who had higher mean urinary sodium
compared to the non-migrants had higher systolic BP. BP rose after a few months
(6.9/6.2mmHg systolic and diastolic), whereas it did not increase in non-migrant.
17
PART II: Say True/False With Specific Reasons
Answer: false
Answer: false
18
Justification: The prevalence can be calculated in cross-sectional studies as a measure
of frequency. The prevalence describes how frequently a specific disease or a specific
risk factor occurs in a population at a defined point in time. Involve comparisons of
the incidence of disease or infection in risk-factor in the study population.
Answer: True
Justification: Epidemiologic design in which the two comparison groups are defined
according to their exposure status to a suspected risk factor of a disease is cohort.
Subjects are defined according to their exposure levels and followed over time for
outcome occurrence
19
Answer: false
An incidence case-control study for a rare disease is less time consuming than
a prospective cohort study for a common disease.
Answer: True
Justification:
20
Answer: false
Justification: Follow up is the major challenge in cohort studies, as well as the major
cost in terms of time. Unless complete or nearly complete information could be
obtained the results might be un-interpretable. If the loss to follow-up is not
comparable between the two exposed groups, this will also be a source for bias.
Therefore, Minimizing loss to follow up is the best way to eliminate bias.
Answer: True
21
Answer: False
Answer: True
Justification: Interventional studies are often prospective and are specifically tailored
to evaluate direct impacts of treatment or preventive measures on disease and
prospectively to assess the effectiveness of the intervention.
Answer: True
22
Justification: blind data collectors regarding exposure or health outcome status and
develop well standardized data collection protocols can help to minimize information
bias
Answer: false
Justification: large sample improve data analysis, reducing random error in the way
information is obtained and recorded, less sampling process error, not related in
reducing information bias.
Answer: false
23
often neither feasible nor ethical. So, one must assess the validity of individual studies
and examine the totality of evidence from all available studies and make a judgment
about the likelihood of a cause effect relationship.
Answer: True
Answer: False
Justification: Selection bias can be reduced by paying attention to the following: The
study population should be clearly identified, the choice of the right comparison/
24
reference group, select participants through randomization, so that they have an equal
chance of receiving the intervention.
Answer: True
Justification: The large size of many populations can provide less reliable information
than a carefully obtained sample and sampling bias on the other hand may be
minimized by the wise choice of a sampling procedure.
Answer: True
Justification: Sensitivity: The number of positive test results for the presence of an
outcome (a) divided by the total presence of an outcome (a+c) Sensitivity = a / (a+c)
Epidemiologists have found that accidents can be avoided and are predictable.
25
Answer: True
Answer: False
Justification: Pandemic refers to an epidemic that has spread over several countries
or continents, usually affecting a large number of people, but an epidemic is the rapid
spread of infectious disease to a large number of people in a given population within
a short period of time.
26
An endemic is an occurrence of disease clearly in excess of normal expectancy.
Answer: False
Answer: True
27
Justification: Oral epidemiology can be defined as the study of distribution and
determinants of oral health related states or events in specified population.
. Mortality is the proportion of people who live from a disease to the population
of a geographic area for a period of time.
Answer: False
Justification: Mortality is the proportion of people who died from a disease to the
population of a geographic area for a period of time
28
Answer: False
Justification: In oral epidemiology, there are a number of crucial terms that will help
dentists to understand how oral disease data is measured and presented. These include
Index: This is a standard method of rating a disease in which there is a graduated,
numerical scale with values corresponding to specific criteria
Answer: False
Justification: Morbidity is not death rate, but it is the rate of disease or proportion of
diseased persons in a geographic area
Answer: False
29
Justification: Environmental epidemiology studies external factors that affect the
incidence, prevalence, and geographic range of health conditions. Environmental
epidemiology seeks to understand how physical, chemical, biologic, as well as, social
and economic factors affect human health.
Justification: Specificity is the proportion of people without the disease who have a
negative test (d/ b+d ).
31
.A longitudinal or prospective study is also referred to as a(n)
A. ecological study
C. cohort study
D. observational study
Answer: C
32
. Cedar Rivers is a community of 100,000 persons in central Iowa. During the
year of the floods (2008 there were 1,000 deaths from all causes. A study of all cases
of tuberculosis found the number of deaths at 300 (200 males and 100 females).
During 2007, there were only 60 deaths from tuberculosis, 50 of them males. The
crude mortality rate for Cedar Rivers in 2008 was
B. 60 per 1,000
C. 10 per 1,000
Answer: C
Justification: The crude mortality rate it the death rate that is calculated using all
deaths as the numerator and the total population as the denominator. Therefore Crude
mortality rate = total deaths/total population = 1000 100000 *100 = 10 per 1,000
33
A. Native B. Epidemiology C. People D. All
Answer: C
Justification: The word Epidemiology comes from the Greek words epi, meaning on
or upon, demos, meaning people, and logos, meaning the study of.
B. Allowance of the direct observation of risk. The exposure factor is well defined
and can study exposures that are uncommon in the population. The temporal
relationship between factor and outcome is known.
Justification: Epidemiologic research methods in which the two study groups are
selected on their disease status. The design is capable of evaluating the association of
a disease to exposure, optimal for the evaluation of RARE diseases, can examine
multiple etiologic factors for a single disease.
A. It is the best because if the sensitivity test correctly identifies all potential cases as
either negative or positive.
C. This is the association between two variables, the exposure and the outcome, and
are measured at the group level.
Answer: C
35
Justification: ecologic correlation uses data from entire population to compare
disease frequencies - between different groups during the same period of time, or in
the same population at different points in time.Does not provide individual data,
rather presents average exposure level in the community.
B. This is beneficial because an association can be found between exposure rates and
disease rates during the same time period.
C. The predictive value is the proportion of people screened positive by a test and
actually have the disease, this is the + value.
Answer: B
36
Justification: ecologic study is used to assess an association that can be found
between exposure rates and disease rates at group level rather than individual.
Justification: concerned with the treatment of disease and action of remedial agents.
The sample should be sick individual to evaluate new treatment methods.
A. When sensitivity tests correctly identify all potential cases as either negative or
positive
37
B. Describes when a definitive diagnosis that has been determined by biopsy, surgery,
autopsy or other method and has been accepted as the standard.
C. Where the investigator manipulates the study factor but does not assign individual
subjects randomly to the exposed and non-exposed groups
Answer: C
B. Was the conclusion true? It is the extent to which you can believe your results
C. It is the third variable that relates to the exposure and the outcome
Answer: A
38
Justification: It concerns generalizability, or inferences to populations beyond the
study's restricted interest. External validity is threatened, for example, when the
investigator attempts to apply the findings of the study to a population which is not
comparable to the population in which the research was completed.
A. Person to Animal
B. Person to Person
C. Object to Person
Answer: B
39
person transfer of the agent from a reservoir to a susceptible host by direct contact or
droplet spread .
B. Resistance of the entire community because of the people immunity within the
community
Answer: C
40
A. Experimental
B. Observational cohort
C. Observational case-control
D. Observational cross-sectional
Answer: D
Justification: Cross sectional study investigate disease and risk factor (exposure)
patterns in a representative sample of a population in a narrowly defined time period.
41
It can be useful to identify associations, generate and test hypothesis and, by repeating
at different time periods, measure change and hence evaluate interventions.
II. ____B______ Occurrence of cancer was identified between April 1991 and July
2002 for 50,000 troops who served in the first Gulf War (ended April 1991) and
50,000 troops who served elsewhere during the same period.
Answer: B
III. ____C______ Persons diagnosed with new-onset Lyme disease were asked how
often they walk through woods, use insect repellant, wear short sleeves and pants,
etc. Twice as many patients without Lyme disease from the same physician’s practice
were asked the same questions, and the responses in the two groups were compare
Answer: C
42
Justification: An “observational” design comparing exposures in disease cases vs
healthy controls from the same population, Subjects are selected with respect to
presence or absence of disease or outcome of interest, and then inquiries are made
about past exposure to the factor(s) of interest. Can examine multiple etiologic factors
for a single disease
Answer: A
Justification:
43
n of many treatments or procedure
1. Strength of the Association - The stronger the association, the more likely that it is
causal.
4. Temporal Relationship - The exposure to the factor must precede the onset of the
disease.
44
5. Dose-response Relationship - The risk of disease often increases with increasing
exposure to a causal agent.
Its principles and methods are used to: describe the health of populations; detect
causes of health problems, quantify the association between ill health and
determinants, test treatments and public health interventions; and monitor changes in
states of health over time.
45
To set policy and plan programs, public health officials must assess the health of the
population or community they serve and determine whether health services are
available, accessible, effective, and efficient. To do this, they need to find answers
for many questions such as:
What are the actual and potential health problems in the community?
Who is at risk?
How do these patterns relate to the level and distribution of services available?
The methods of descriptive and analytic epidemiology provide ways to answer these
and other related questions.
46
Epidemiology uses community diagnosis as approach to identify community health
need. Community diagnosis is a process of identification and detailed description of
the most important health problems (what is the interest of the community? what they
need to be solved for them?) of a given community.
In order to prioritize these community health problems the following criteria should
be considered
47
Finally, add up all the scores given for every criterion for specific disease or health
problem and prioritize according to rank. The disease or health problem with the
highest scores will be given priority in that community.
Many of the known causes of diseases are identified using epidemiologic methods.
48
means determining things such as the appropriate length of stay in hospital for
specific conditions, the value of treating high blood pressure, the efficiency of
sanitation measures to control diarrheal diseases will be evaluated for their
effectiveness and efficiency using epidemiological methods.
Screening programs:
The basic principles of epidemiology are applied in the planning and execution of
screening program.
50
o Screening and early treatment of diseases is one of the main strategies of disease
prevention program in public health practice
51
expected level. But sometimes disease may occur in excess of what is expected level.
In epidemiology the concept epidemic and pandemic are used to describe the level of
the disease occurrence in the community.
Hyper endemic is an endemic disease that affects a high proportion of the population
at risk.
52
If occurrence of a health-related event within an area or population that is clearly in
excess of the expected level for a given time period then the occurrence level is
Epidemic outbreak.
53
Early Concepts of Disease
Many early conceptions of the cause of disease were rooted in superstitions and
religion. Many felt that disease was punishment from God (or Gods depending on
their faith) and would pray or try to make amends with the God(s) they angered to
cure themselves of disease
54
Physical environment: safe water and clean air, healthy workplaces, safe
houses, roads, access and use of services drinking and eating pattern of the
people
Hunter-Gatherers
Ten thousand years ago humans were hunter-gatherers. They had a short life span,
but not because of epidemics; their primary problem was just finding enough food to
eat. They lived and traveled in small groups and hunted and foraged for food. Their
mixed diet was probably fairly balanced and nutritionally complete.
55
Early explanations for the occurrence of disease focused on superstition, myths, and
religion. Primitive peoples believed in natural spirits that were sometimes
mischievous or vengeful
The shift from the hunter-gather mode of living to an agricultural model provided a
more secure supply of food and enabled expansion of the population. However,
domesticated animals provided not only food and labor; they also carried diseases
that could be transmitted to humans. People also began to rely heavily on one or two
crops, so their diets were often lacking in protein, minerals, and vitamins. People
began living in larger groups and staying in the same place, so there was more
opportunity for transmission of diseases.
Garbage and waste accumulated, and rodents and insect vectors were attracted to
human settlements, providing sources of disease. The engraving below shows a
woman emptying her bedpan into the street of a medieval village.
56
The Hippocratic Corpus
For many centuries explanations for disease were based not on science, but on
religion, superstition, and myth.
The Hippocratic Corpus was an early attempt to think about diseases, not as
punishment from the gods, but as an imbalance of man with the environment.
Although it was unsophisticated by today's standards, it was an important step
forward. By considering the possibility that disease was associated with
environmental factors or imbalances in diet or personal behaviors, the Corpus also
opened up the possibility of intervening to prevent disease or treat it.
Despite the contributions of the Corpus, medical and scientific progress in Europe
was arrested for several centuries. The population grew, and cities became densely
populated, but there was little attention to waste disposal and sanitation. These factors
set the stage for endemic disease and periodic epidemics.
57
The Bubonic Plague (1347-1700s)
Bubonic plague is an acute infectious disease caused by the bacterium Yersinia pestis.
The cause of the plague was not known, but there were many theories. The most
popular explanation was that it was caused by "miasmas," invisible vapors that
emanated from swamps or cesspools and floated around in the air, where they could
58
be inhaled. Others thought it was spread by person to person contact, or perhaps by
too much sun exposure, or by intentional poisoning.
The miasma theory was the most popular, however. One of the popes kept large fires
burning at both ends of the room he worked in order to counteract the miasmas. The
illustration on the left shows a "plague doctor," who is covered from head to toe,
including a hood, a mask, gloves, and a beak-like sack on his nose. The covering on
the nose contained aromatic herbs, which were believed to neutralize miasmas
The use of quarantine as a public health measure dates back to the 14th century
when the Black Death ravaged Italy and the rest of Europe. Quarantine comes from
the Italian quarantena, meaning forty-day period. Travelers and merchandise that
had potentially been exposed to disease were isolated for a period of time to ensure
that they weren't infected.
59
In the history of community health and public health nursing, there were many
milestones that to some levels were impeding the progress of ensuring community
health and public health nursing.
Period of bacteriology”
laboratory isolation and culture
Preventive approach
interrupt transmission of the infectious agent
Era of chronic disease epidemiology
Focus on risk factors at individual level Germ theory: infectious disease era.
The "black box" approach
Exposures are related to outcomes without understanding the intervening
factors or pathogenesis (SusserandSusser1996).
Primary analytic methods
Risk ratios to relate exposures to outcomes.
Preventive measures
61
Number of epidemiologists grown rapidly along with epidemiology training
programs
Many sub-specialties have been established
Multi-level causality
focus on risk factors as well as casual pathways at the societal level and with
pathogenesis at the molecular level
Cascade of causation from risk factors to molecular causes of diseases.
Elaborated on the host-agent-environment harmony where in each of these
factors affects the other
62
Historical Evolution of Epidemiology
460 B.C– Hippocrates, the father of modern medicine. For the first time
in the fifth century B.C. he suggested that the development of human
disease might be related to the external as well as personal environmental
of an individual.
63
1787-1872. Pierre Charles Alexandre Louis, sometimes called the “Father
of Epidemiology”, systematized the application of numerical thinking (“la
methode numerique”) and championed its cause. Using quantitative
reasoning, he demonstrated that bloodletting was not efficacious therapy,
and wrote books on tuberculosis and typhoid. NLouis' influence was
widespread, primarily through his students.
1839 - William Farr took responsibility for medical statistics in the Office
of the Registrar General for England and Wales. He extended the
epidemiologic analysis of morbidity and mortality data, looking at effects
of marital status, occupation, and altitude.
1854 - John Snow demonstrated that the risk of mortality due to cholera
was related to the drinking water provided by a particular
64
1950's-1970's. Major epidemiology successes in the area of – fluoride,
tobacco, blood pressure and stroke, CHD risk factors, toxic shock
syndrome, Legionnaire's disease, Reye’s syndrome, endometrial cancer
and exogenous estrogens.
65
Fig 1 steps of the scientific method.
There are various forms of this step. Sometimes you may want to
state an objective and a problem and then phrase it in the form of a
question. The reason it’s good to state a question is because it’s
66
easiest to design an experiment to answer a question. A question
helps you form a hypothesis, which focuses your study.
67
Do the results support the hypothesis or not? Keep in mind, it’s okay if
the hypothesis is not supported, especially if you are testing a null
hypothesis. Sometimes excluding an explanation answers your question!
There is no “right” or “wrong” here. However, if you obtain an
unexpected result, you might want to perform another experiment.
John Snow had long been skeptical of the then dominant miasma
theory that diseases like cholera were caused by a noxious form of foul
air:
68
Miasma was considered to be a poisonous vapor or mist filled with
particles from decomposed matter (miasmata) that caused illnesses. The
Miasmatic position was that diseases were the product of environmental
factors such as contaminated water, foul air, and poor hygienic conditions.
Such infection was not passed between individuals but would affect
individuals who resided within the particular locale that gave rise to such
vapors. It was identifiable by its foul smell.
There was no proof miasma theory was true so Snow rejected the theory
and sought to find a proper one. When a virulent cholera epidemic broke
out in London in 1854, Snow investigated. Through interviews he
collected data about which houses cholera deaths occurred in. In his later
study the data was plotted in the form of a spot map, as shown.
69
Fig 2 spot map of cholera deaths in London in 1854.
On proceeding to the spot, he found that nearly all the deaths had taken
place within a short distance of the [Broad Street] pump. There were only
ten deaths in houses situated decidedly nearer to another street-pump. In
five of these cases the families of the deceased persons informed me that
they always sent to the pump in Broad Street, as they preferred the water
to that of the pumps which were nearer. In three other cases, the deceased
were children who went to school near the pump in Broad Street....
With regard to the deaths occurring in the locality belonging to the pump,
there were 61 instances in which I was informed that the deceased persons
used to drink the pump water from Broad Street, either constantly or
occasionally...
The result of the inquiry, then, is, that there has been no particular
outbreak or prevalence of cholera in this part of London except among the
persons who were in the habit of drinking the water of the above-
mentioned pump well.
On the basis of this evidence Snow concluded that drinking water from
the Broad Street well pump caused cholera. It was a radical hypothesis for
the time.
70
Snow then devised an experiment so simple it rings in the minds of
scientists to this day. The experiment was to remove the Broad Street
pump handle immediately. If the hypothesis was true this would stop the
cholera epidemic. Continuing the above quote:
The pump handle was removed. The epidemic ended. Deaths quickly
trailed off and fell to zero. Those who had fled the neighborhood moved
back and life soon returned to normal.
Since the epidemic had already started to fade it was not clear if the
experiment proved the hypothesis or not:
The report concluded that: Diseases which are communicated from person
to person are caused by some material which passes from the sick to the
healthy, and which has the property of increasing and multiplying in the
systems of the persons it attacks. In syphilis, smallpox, and vaccinia, we
have physical proof of the increase of the morbid material, and in other
communicable diseases the evidence of this increase, derived from the
fact of their extension, is equally conclusive. As cholera commences with
an affection of the alimentary canal, and as we have seen that the blood is
71
not under the influence of any poison in the early stages of this disease.it
follows that the morbid material producing cholera must be introduced
into the alimentary canal [and] must, in fact, be swallowed accidentally,
for persons would not take it intentionally....
72