2024-2025 Raisbeck Aviation C Invitational

January 18, 2025

Disease Detectives
TEST
DO NOT OPEN OR START TEST UNTIL INSTRUCTED!

Tie Breakers (TB): 7, 9, 11, 16, 23, 27, 43, 50, 70, 117, 129, 138
• Do not write in Test Packet.
• Test may be double-sided. Please check.
• No partial credit.
• Write legibly.
• Point values noted in each section’s header
• Use of any electronic device other than a scientific calculator will result in disqualification.
• You can separate the pages, but after exam, please re-order and staple back together in correct order
• RECORD ALL ANSWERS ON THE SEPARATE ANSWER SHEET.

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 Part 1 – Multiple Choice (64 points total, 2 points each)
6) During which of the following stages of the natural
1) According to the Center for Disease Control and history of disease is a person least likely to be
Prevention (CDC), which one of the following major contagious?
determinants has the greatest effect on the health of a A. Convalescent period
population? B. Incubation period
A. Genes and biology C. Latent period
B. Health behaviors D. Preclinical period
C. Medical care access and quality E. Prodromal period
D. Social and societal characteristics
E. Physical environment 7) Which of the following best describes the reservoir for
malaria in the chain of transmission?
2) According to the CDC’s Prevention Status Report of A. Anopheles mosquitoes
2018, which one of the following is NOT among the B. Humans
top 10 most important public health concerns in the C. Plasmodium falciparum
USA? D. Skin
A. Alcohol-related harms E. Stagnant water
B. Mental health disorders
C. Nutrition, physical activity, and obesity 8) Which of the following is the least common portal of
D. Prescription drug overdose entry for infectious diseases in humans?
E. Tobacco use A. Blood
B. Gastrointestinal tract
3) All of the following are examples of observational C. Genitourinary tract
studies EXCEPT? D. Respiratory tract
A. Case series E. Skin
B. Case-control study
C. Clinical trial 9) What type of maps was used by John Snow to study
D. Cohort study cholera in London in the 1850’s?
E. Ecological study A. Cartogram maps
B. Chloropleth maps
4) Typhoid Mary was cook with Salmonella typhi C. Heatmaps
colonizing her gallbladder who spread typhoid fever to D. Spot maps
many people she served food to. Which of the E. Thematic maps
following best describes the relationship between her
and the Salmonella bacteria living in her gallbladder? 10) Which of the following is not a vector for human
A. BFF disease?
B. Commensalism A. Fleas
C. Competition B. Flies
D. Mutualism C. Rodents
E. Parasitism D. Snails
E. Tapeworms
5) Which of the following stages of the natural history of
disease best describes the time period when the 11) A pathogen causes severe disease in 20% of those
disease is present but not yet diagnosed? infected and has an infectivity rate of 5%. How many
A. Convalescent period people will develop severe disease in a population of
B. Incubation period 50,000 people within which 40% of the population are
C. Latent period susceptible?
D. Preclinical period A. 50
E. Prodromal period B. 200
C. 500
D. 2,500
E. 4,000

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 17) To assess the association between Parkinson’s disease
12) Which of the following diseases has a high and pesticide exposure, investigators conducted a case-
pathogenicity but low virulence? control study with 100 patients with Parkinson’s
A. Ebola disease and 100 healthy controls. Among the patients
B. Avian influenza with Parkinson’s disease, 50 had a history of pesticide
C. HIV exposure. Among the controls, the number with a
D. Norovirus history of pesticide exposure was 25. For this study,
E. Tuberculosis the odds ratio was:
A. 0.5
13) Which of the following diseases has a low B. 1.5
pathogenicity but high virulence? C. 2
A. Ebola D. 3
B. Avian influenza E. Cannot determine from the information
C. HIV provided
D. Norovirus
E. Tuberculosis 18) When comparing randomized controlled trials (RCT)
to cohort studies, which of the following is generally
14) For a potentially fatal disease such as Ebola, the most true?
appropriate measure to describe the frequency of A. Results of RCT are less likely affected by
death from the disease is the? confounding
A. Attack rate B. Both are prospective
B. Case-fatality rate C. Results of RCT are less likely to be
C. Incidence rate generalizable than results of cohort study
D. Mortality rate D. A, B, and C are all true
E. Standardized mortality ratio E. None of the above

15) A new mutation in Ebola increases virulence but does 19) The strength of an association between exposure and
not increase infectivity. Which of the following will outcome is best measured by the:
occur? A. Attributable risk
A. Prevalence will increase B. Attributable fraction
B. Prevalence will decrease C. Odds ratio
C. Incidence will increase D. Population attributable risk
D. Incidence will decrease E. Relative risk
E. None of the above
20) A screening test of known sensitivity and specificity is
16) A controversy arose between the proponents of applied to two populations. The prevalence of the
medication versus lifestyle changes to treat patients disease being screened for is 20% in population A and
with type 2 diabetes. To support their position, one 2% in population B. Which of the following is true?
group wrote: “Of 150 patients with type 2 diabetes, A. The sensitivity will be lower in population A
120 showed improved blood sugar control following than B
lifestyle changes leading to weight loss” Their B. The specificity will be lower in population A
inference that in type 2 diabetes patients, lifestyle than B
changes are the therapy of choice is: C. The percentage of all positive tests that are
A. Correct, because most patients showed false positives will be lower in population A
improved blood sugar control than in population B
B. Correct, because weight loss also occurred D. The percentage of all negative tests that are
C. Incorrect, because the inference is not based false negatives will be lower in population A
on rate than in population B
D. Incorrect, because there is no comparison E. None of the above
group
E. None of the above

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21) The crude mortality rate in Community X was higher A. To advise the patient about common risk
than the crude mortality rate in Community Y, but the factors and the usual course of the illness,
age-adjusted mortality rate was higher in Community after reviewing such information in
Y than in Community X. This indicates that: appropriate reference material
A. There was confounding B. To develop hypotheses about the cause of
B. Investigators made a calculation error the outbreak
C. The population of Community X is on C. To verify the clinical findings as part of
average older than that of Community Y verifying the diagnosis
D. The population of Community Y is on D. To verify the laboratory findings as part of
average older than that of Community X verifying the diagnosis
E. No inference can be made about the average E. To provide emotional support to patients
ages of the 2 communities during the outbreak

22) Factor A, B, or C can each individually cause a certain 26) A study was conducted to assess the effectiveness of a
disease without the other 2 factors, but only after vaccine in preventing Lassa fever, a viral hemorrhagic
exposure to factor X. Exposure to factor X alone does fever common in West Africa. Patients were
not cause the disease, but the disease never develops randomized into groups that either received the trial
in the absence of exposure to factor X. Factor X can vaccine or a placebo injection. Trial data is presented
be described as: below. Which of the following methods is the most
A. A necessary and sufficient cause appropriate to assess the statistical significance of
B. A necessary but not sufficient cause these results?
C. A sufficient but not necessary cause Developed No Lassa Total
D. Neither necessary nor sufficient Lassa fever fever
E. None of the above Vaccine 56 865 921
given
23) Factor A from question 22 can be described as: Placebo 166 722 888
A. A necessary and sufficient cause given
B. A necessary but not sufficient cause 222 1587 1809
C. A sufficient but not necessary cause A. Analysis of variance
D. Neither necessary nor sufficient B. Chi-square test
E. None of the above C. Multiple logistic regression
D. Paired t-test
24) To investigate the association between a new dietary E. Pearson correlation coefficient
supplement and the occurrence of gastrointestinal
(GI) issues, investigators conducted a case-control
study with 50 case-patients and 100 controls. Among
the 50 individuals with GI issues, 35 reported taking 27) A clinical trial is being conducted on a new medication
the dietary supplement. Among the 100 controls, 40 (drug X) to treat high blood pressure compared to
reported taking the dietary supplement. The resulting lisinopril. The study consists of 200 subjects being
odds ratio for the association between taking the prescribed drug X and another 200 subjects prescribed
dietary supplement and GI issues is: lisinopril for 1 year. Their blood pressures were
A. 1.8 measured both at the beginning and the end of the
B. 2.0 study period. Which of the following method of
C. 2.8 statistical analysis is best for determining whether drug
D. 3.5 X is more effective than lisinopril?
E. 4.0 A. One-tailed chi-square test
B. Two-tailed chi-square test
C. One-tailed t-test
D. Two-tailed t-test
25) Why should an investigator who has no clinical E. Analysis of variance
background nonetheless talk to a patient or two as an
early step in the outbreak investigation?

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28) A cohort study is performed to study the association myocarditis occurring in 18 of the patients out of
between the consumption of a diet high in ultra- 600,000 subjects in the study. Which of the following
processed foods and the development of obstructive phases of clinical trials does this study most likely
sleep apnea in men aged 40-60 years. The cohort is belong to?
followed for 10 years, and the attributable risk is found A. Pre-clinical
to be 0.26. How many patients need to be exposed to B. Phase I
a diet high in ultra-processed foods for one more C. Phase II
subject to develop obstructive sleep apnea? D. Phase III
A. 0.26 E. Phase IV
B. 0.74
C. 1.35 31) A novel compound is being studied for potential
D. 3.85 treatment of metastatic colorectal cancer, the
E. Unable to determine from the information compound is being tested in cultures colorectal cancer
provided cells to determine efficacy, and in rats to assess for
adverse effects. The above represents which of the
29) A preventive care doctor is researching into the following phases of drug development?
relationship between a person’s height in centimeters A. Drug discovery
and body weight in kilograms. Data from 200 patients B. Pre-clinical
were obtained and analyzed. The following formula C. Clinical
showed a linear relationship in a regression model. D. Regulatory approval
E. Post-marketing surveillance
y(x) = -125 + 1.2x
R = 0.75 32) A new test is being developed to diagnose Lassa virus
infection. The older standard test A has a sensitivity of
According to this model, which of the following is the 86% and specificity of 88%, while the newer test B has
most likely body weight for an individual measuring a sensitivity of 96% and specificity of 88%. If 300
170 cm in height? people undergo testing with both test A and test B,
A. 65 kg which of the following is true?
B. 72 kg A. Test B will correctly identify more people
C. 80 kg with Lassa than test A
D. 90 kg B. Test B will correctly identify less people with
E. Unable to determine from the information Lassa than test A
provided C. Test B will correctly identify more people
without Lassa than test A
30) A study is carried out over 1 year to study the long- D. Test B will correctly identify less people
term effects of a new vaccine against SARS-CoV-2, without Lassa than test A
which causes coronavirus disease 19 (COVID-19). E. The prevalence of Nipah is needed to
They found that the vaccine is associated with determine whether test A or test B will
increased incidence of fever of unknown origin and correctly identify more people with Nipah

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Part 2 – Matching (80 points total, 1 point each)
Questions 33-40: Choose ONE of the following (A to C) 50) Developed the oral polio vaccine
that best matches each example below: 51) The “English Hippocrates” who suffered from gout and
A. Clinical approach studied its natural history
B. Public health approach 52) Identified an antibacterial agent from mold
C. BOTH clinical and public health approaches 53) Performed landmark study linking cigarette smoking to
lung cancer
33) Prenatal care for expectant mother 54) Disproved the theory of spontaneous generation
34) Smoking cessation campaign 55) Pioneer in the study of disease transmission, including of
35) Screening for diabetes in a community fair syphilis and rabies
36) Potassium iodide distribution during radiation emergency 56) Pioneer in health economics and helped to develop the
37) Public education about dangers of opioid abuse US National Health Survey
38) Clinical trial for a new cancer prevention test 57) Made numerous contributions to epidemiology including
39) Conducting a cognitive behavioral therapy session developing systems to comprehensively classify diseases
40) Screening and treating high risk population for and to collect and analyze vital statistics
tuberculosis
Questions 58-71: Match ONE of the following time
Questions 41-46: Match each type of variable below (A to periods below (A to F) to when a major event or advance
D) with each item (each option can be used once or more in medicine, epidemiology, or public health first occurred
than once): (each time period may be used once or more than once):
A. Nominal A. Before 500 CE (Ancient Times)
B. Ordinal B. 500 – 1500 CE (Medieval Period)
C. Interval C. 1500 - 1800 CE (Traditional and Pre-Modern
D. Ratio Medicine)
D. 1800 - 1900 CE (Early Modern Medicine)
41) SAT score E. 1900 - 1990 CE (Later Modern Medicine)
42) Blood glucose level F. 1990 - Present (Contemporary Medicine)
43) Cancer stage
44) Music genre 58) Waterborne nature of cholera studied using analytic
45) Height in centimeters epidemiology
46) Hair color 59) An oath of ethical standards for physicians
60) Discovery of penicillin
Questions 47-57: Match ONE of the following prominent 61) Human genome project
historical figures in the history of public health and 62) Ether used an anesthesia
epidemiology to an accomplishment or description below 63) First ever successful vaccine
(each person is used only once): 64) Sewage system effectively moving waste away from
A. Austin Bradford Hill drinking water source
B. Louis Pasteur 65) Smallpox eradicated via worldwide childhood vaccination
C. Brian MacMahon program
D. William Farr 66) Cigarette smoking linked to development of lung cancer
E. Joseph Goldberger 67) Phlebotomy
F. Jonas Salk 68) The Black Death
G. Albert Sabin 69) Spanish flu pandemic
H. Alexander Fleming 70) Aqueducts to supply clean water
I. Thomas Sydenham 71) Large scale chlorine disinfection of water
J. Girolamo Fracastoro
K. Edgar Sydenstricker

47) Pioneer in study of epidemiology of chronic diseases such

as cancer, especially breast cancer
48) Studied pellagra and its links with diet and poverty in the
southern US when mortality was as high as 40%
49) Developed the injectable polio vaccine

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Questions 72-82: Match ONE of the following death toll 97) Avoiding invasive treatment for an indolent cancer
ranges below (A to E) to a corresponding pandemic or 98) Offering smoking cessation interventions in patients with
epidemic in human history (each choice is used once or emphysema
more than once):
A. < 1000 deaths Questions 99-106: Match one of the following types of
B. 1000 to 1 million deaths surveillance listed (A to D) with each example below
C. 1 million to 40 million deaths (each option is used once or more than once):
D. 40 million to 100 million deaths A. Active surveillance
E. > 100 million deaths B. Passive surveillance
C. Sentinel surveillance
72) SAR-CoV2 (COVID-19) D. Syndromic surveillance
73) Spanish flu pandemic
74) The Black Death 99) Hospital staff reporting unusual spikes in flu-like
75) Cholera pandemics of 1817 to 1923 symptoms to health authorities
76) Swine flu (H1N1) of 2009 100) Routine reporting of cases of notifiable diseases by
77) Ebola epidemic of 2013-2016 clinicians to public health authorities
78) MERS epidemic of 2012 101) A laboratory network collecting antibiotic resistance data
79) HIV / AIDS pandemic since 1981 from selected hospitals
80) New World smallpox epidemics of 1500’s to 1900’s 102) Monitoring emergency department visits for
81) Antonine Plague (likely smallpox) of 165 to 190 gastrointestinal symptoms to detect potential outbreaks of
82) The Third Plague of 1894-1940 foodborne illness
103) Conducting door-to-door surveys to collect data on the
Questions 83-90: Choose the SINGLE most accurate spread of a new infectious disease
current state of disease management (A to D) to match to 104) Health departments requesting weekly reports from
each disease below (each option is used once or more selected clinics on the number of influenza-like illness
than once): cases
A. Disease control 105) Using electronic health records to track increases in
B. Disease elimination respiratory symptoms for early identification of potential
C. Disease eradication outbreaks
D. Disease extinction 106) Clinicians voluntarily reporting cases of a rare disease to a
centralized database
83) Smallpox worldwide
84) Rubella in USA Questions 107-112: Match each scenario below with the
85) Poliomyelitis in USA ONE best description of disease frequency below (A to F)
86) Malaria worldwide A. Endemic
87) Rinderpest worldwide B. Outbreak
88) Tuberculosis worldwide C. Epidemic
89) Rabies in USA D. Pandemic
90) Yellow fever in USA E. Cluster
F. Sporadic
Questions 91-98: Choose the SINGLE best level of
prevention for each example below (each option is used 107) More than 80 million people infected with HIV across
once or more than once): the continents since early 1980’s
A. Primordial prevention 108) More than 300 cases of norovirus occurred on a cruise
B. Primary prevention ship in the Caribbean
C. Secondary prevention 109) More than 200 million people are infected with malaria
D. Tertiary prevention annually in Africa
E. Quaternary prevention 110) Three people contracted rabies via bites from an infected
raccoon
91) Vaccination against measles 111) Ebola infected more than 28,000 people resulting on
92) Mammogram for breast cancer screening 11,310 deaths in 2014-2016, primarily in the neighboring
93) Implement policy to reduce air pollution in a city countries Guinea, Liberia, and Sierra Leone
94) Screening for diabetes at the country fair 112) Contaminated cooling towers in New York City led to
95) Rehabilitation after a heart attack 138 cases and 16 deaths from Legionnaires’ disease in
96) Reduce occupational exposure to harmful chemicals 2015

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Part 3 – Case Study (56 points total, 2 points each)
Section 1: Acute Gastroenteritis Outbreak on the Pacific Crest Trail
In the summer of 2022, hikers on the Pacific Crest Trail (PCT) experienced a significant outbreak of a gastrointestinal illness. The
PCT stretches 2,650 miles from California’s border with Mexico to Washington state’s border with Canada, attracting hikers from
around the world. The Centers for Disease Control and Prevention (CDC) launched an investigation after numerous hikers
reported symptoms of nausea, vomiting, diarrhea, and stomach cramps within the PCT in Washington state. These symptoms are
suspicious for acute gastroenteritis (AGE).

113) All of the following are important steps in the beginning of an outbreak investigation EXCEPT?
A. Establish a case definition
B. Establish background rate of disease
C. Identify and interview affected individuals
D. Initiate surveillance
E. Prepare for field work

114) All of the following may be included as part of a case definition for this outbreak investigation EXCEPT?
A. Summer of 2022
B. The Pacific Crest Trail
C. Hikers on the PCT
D. Nausea, vomiting, diarrhea, stomach cramps
E. Acute gastroenteritis

115) Which of the following considerations is most important when creating a case definition early on during an outbreak
investigation?
A. Capturing the broadest possible range of potential cases
B. Defining the exact pathogen involved in the outbreak
C. Ensuring the case definition is highly specific to exclude unrelated cases
D. Establishing the geographic boundaries of the outbreak area
E. Including only laboratory-confirmed cases to maintain accuracy

Many who hike the PCT are members of online social media groups who communicate and share their experiences through social
media. An investigation of social media postings on September 5, 2022 found 27 reports of hikers with AGE symptoms on the
Washington PCT during the previous month, 26 of whom provided information about date of symptom onset. Numerous
additional reports without specific date of onset were found, suggesting that AGE was occurring commonly during the 2022 PCT
hiking season.

116) Which of the following is NOT an advantage of using social media engagement to identify cases in an outbreak
investigation?
A. Ability to reach individual who might not seek medical care
B. High reliability and accuracy of reported information
C. Identification of potential outbreak clusters
D. Increased public awareness and engagement in reporting cases
E. Rapid collection of real-time data from an extended population

117) If no specific date of onset was provided by some survey respondents during an outbreak investigation, which of the
following is the most important reason for why these subjects were excluded from the study analysis?
A. Subjects' overall health status cannot be accurately evaluated
B. Ability to track the progression of the illness is hindered
C. Cannot accurately identify the exposure period
D. Hinders ability to collect biological samples for laboratory testing
E. The subjects' demographic data might not match the typical outbreak profile

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During September 13–18, a REDCap (Research Electronic Data Capture) survey was posted on a Facebook group popular with
Washington PCT hikers. A quick response (QR) code was prominently displayed at trailhead locations where illnesses had been
reported. Survey responses were obtained from 27 ill PCT hikers regarding symptoms, locations, and contact details; 22 of the 27
respondents reported onset dates. Two of the respondents, the only two with symptoms during the preceding 14 days who were
still in Washington, agreed to provide stool samples. Both samples tested positive for norovirus at the Washington State Public
Health Laboratory.

118) Which one of the following statements provides the most relevant reason for why stool samples were collected from only 2
respondents of the surveys?
A. The CDC needed only a small sample size to identify the causative agent
B. The other respondents refused to participate
C. The other respondents had already recovered
D. The 2 respondents were available within the geographical area
E. The 2 respondents had recent symptoms which provided better chance to identify the causative agent

119) Which of the following is the most likely laboratory technique used to confirm the presence of norovirus in the stool
samples?
A. Chromatography
B. DNA microarray
C. Enzyme-linked immunosorbent assay (ELISA)
D. Reverse transcriptase polymerase chain reaction (RT-PCR)
E. Western blotting

The 2 positive stool samples were then sent to CaliciNET Laboratory (California Department of Public Health) for genome
sequencing; both were identified as the strain GII.10[P16]. Twenty (74%) survey respondents reported an illness of short duration
(median = 2.5 days; 95% CI = 1–15.7 days); among 22 (81%) who reported signs and symptoms, the most common symptoms
were fatigue (21; 95%) and vomiting and diarrhea (17; 77%). Twenty-one (95%) survey respondents who reported an onset date
noted that they became ill within a 73-mile stretch of the Washington PCT.

120) Which of the following provides the weakest support for the inference that norovirus is the causative agent for most of or
all the survey respondents?
A. Absence of alternative explanation
B. Geographic proximity of the cases
C. Laboratory confirmation of the same norovirus strain in both samples tested
D. Symptom similarity between cases
E. Temporal clustering of the cases

121) Which of the following statements is most likely to be FALSE based on the information provided?
A. Median duration of illness was 2.5 days
B. Fatigue was the most common symptom
C. Five of the 27 respondents experienced no symptoms
D. Some who fell ill had symptoms lasting more than 2 weeks
E. Most who fell ill experienced gastrointestinal symptoms

122) Given that most cases occurred within a 73-mile stretch of the Washington PCT, which of the following can best be inferred
about the nature of the outbreak?
A. Environmental exposure was a likely factor
B. The illnesses were unrelated and coincidental
C. The illnesses were caused by an airborne pathogen
D. The illnesses were caused by contaminated food
E. There was direct person-to-person transmission

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The following is the epidemic curve for the summer 2022 norovirus outbreak on the PCT:

123) Based on the epidemic curve data on the previous page 126) What is the primary mode of transmission for
and the case information provided so far, which of the norovirus?
following is the LEAST likely pattern of spread? A. Airborne
A. Common point source B. Bloodborne
B. Common persistent source C. Direct contact with infected animals
C. Common intermittent source D. Direct person-to-person
D. Propagated source E. Fecal-oral
E. Mixed sources
127) Which environmental factor on the PCT is least likely
124) What is the usual incubation period for most common to influence the occurrence of the AGE outbreak?
viral causes of AGE, such as norovirus, that would be A. Contaminated water sources
relevant in the context of this outbreak? B. Differences in wildlife across trail sections
A. Less than 6 hours C. Limited access to sanitation resources
B. 12-48 hours D. Overcrowded camping sites
C. 3-7 days E. Seasonal variations in climate
D. 10-14 days
E. 2-6 weeks

125) Which of the following is the most likely reason why

the 2 cases with onset of illness on July 20 are not
index cases for the outbreak?
A. There should only be a single index case
B. These 2 cases were not tested for the
causative agent
C. Their date of illness onset was too early
D. There are likely to be missing cases that were
unreported
E. There are usually no index cases for
norovirus outbreaks

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The probable distance an infected hiker could have walked during the norovirus incubation period was used to estimate a
probable geographic exposure area. Focusing within the estimated exposure area, several facilities were identified on the trail for
potential environmental sample collection, including two sets of pit latrines, a rest stop cabin, and a stream commonly used for
drinking water.

During October 3–4, 2022, samples were collected from drinking water sources used by hikers, and from high-touch surfaces in
the cabin and pit latrines. Samples were tested for norovirus and fecal contamination. Norovirus was not detected in any of the
samples. All surface swabs inside the cabin and pit latrines tested positive for human-specific fecal contamination. No culture-
based fecal indicators, E. coli, or human-specific fecal contamination were detected in any water source.

Despite absence of detection of norovirus from environmental sampling, the symptom profiles, the respondent and
environmental laboratory results, and the epidemiologic links all supported the conclusion that the outbreak was primarily caused
by norovirus, and that exposure to contaminated surfaces within the cabin and pit latrines likely amplified transmission.

The CDC disease detectives published their data in their Morbidity and Mortality Weekly Report (MMWR) in September 2023.
The investigation highlighted the challenges of managing a viral outbreak in a remote, outdoor environment, the limited access to
healthcare, the transient nature of the hiking population, and difficulties in maintaining proper hygiene. They emphasized the
importance of personal hygiene, environmental disinfection, and proper food and water safety practices to prevent future
outbreaks on the PCT. They shared improved sanitation protocols and guidance on outbreak reporting and using social media as
a surveillance tool.

128) Based on the CDC team’s work and their conclusions,

which of the following is the LEAST plausible reason
for why norovirus was not detected on the 130) All EXCEPT which of the following are typical features
environmental samples from the cabin and pit latrines in the CDC’s MMWR?
used by affected hikers. A. Editorial opinions
A. The samples were collected too late, after the B. Field investigations
outbreak is over C. Public health alerts
B. The viral load was too low in the samples to be D. Surveillance summaries
detected E. Vital statistics
C. Improper sample collection or handling
degraded the sample quality 131) Which of the following most strongly supports the CDC
D. Environmental factors such as humidity and team’s conclusions about the etiology of this AGE
sunlight destroyed the virus outbreak?
E. The environmental samples came from sources A. Environmental sample test results
not related to the outbreak B. Stool test results
C. Symptom profiles
129) Which of the following is LEAST effective at preventing D. Pattern and timing of the outbreak
transmission of norovirus? E. Pre-existing knowledge about the pathogen
A. Avoiding close contact with persons affected
by gastrointestinal symptoms
B. Boiling drinking water
C. Disinfecting high-touch surfaces and objects
with bleach
D. Sterilizing hands with alcohol sanitizer
frequently
E. Washing hands with soap and water after using
bathroom

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Section 2: ABO Blood Group and Susceptibility to Norovirus Infection

The ABO blood group system classifies human blood into four main types based on the presence or absence of antigens on the
surface of red blood cells:

1. Type A: Has A antigens on the surface of red blood cells and anti-B antibodies in the plasma.
2. Type B: Has B antigens on the surface of red blood cells and anti-A antibodies in the plasma.
3. Type AB: Has both A and B antigens on the surface of red blood cells, and neither anti-A nor anti-B antibodies in the
plasma. This type is known as the universal recipient.
4. Type O: Has neither A nor B antigens on the surface of red blood cells, and both anti-A and anti-B antibodies in the
plasma. This type is known as the universal donor.

This system is important for blood transfusions, organ transplants, and pregnancy, as incompatible blood types can lead to
serious immune reactions. Interestingly, ABO blood group has been shown in multiple studies to be susceptibility factors for
norovirus infection. A systematic review and meta-analysis were published in early 2020 on this topic in the journal Infection,
Genetics, and Evolution.

132) What is the first step in conducting a systematic

review? 135) Which of the following statements about systematic
A. Assessing quality of studies reviews is FALSE?
B. Data extraction A. They help identify gaps in existing research
C. Formulate a research question B. They provide a high level of evidence for
D. Identifying relevant studies clinical guidelines
E. Summarizing the evidence C. They use rigorous methodologies to minimize
bias
133) Why is a meta-analysis often performed as part of a D. They can include both qualitative and
systematic review? quantitative studies
A. To estimate overall effect size by pooling E. They eliminate the need for expert judgment
multiple studies
B. To eliminate heterogeneity of included 136) What is the purpose of a 'forest plot' in a meta-
studies analysis?
C. To identify new research gaps A. To estimate overall effect size by pooling
D. To minimize publication bias multiple studies
E. To standardize individual study B. To eliminate heterogeneity of included
methodologies studies
C. To identify new research gaps
134) Which of the following statements about systematic D. To minimize publication bias
review and meta-analysis is LEAST accurate? E. To standardize individual study
A. Systematic reviews use rigorous methodologies
methodologies to locate and appraise relevant
studies 137) What is a common method used to address publication
B. Meta-analysis involves statistically combining bias in systematic reviews?
the results of multiple studies to increase A. Conducting a sensitivity analysis
overall power B. Including only studies with statistically
C. Systematic reviews are prone to bias and less significant results
reliable than individual trials C. Limiting the review to a single database
D. Meta-analysis often includes data from D. Performing a meta-regression analysis
randomized controlled trials E. Using a funnel plot to visualize asymmetry
E. Meta-analysis results can be influenced by the
heterogeneity of included studies

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In this study, 17 articles covering 2304 participants were included. The overall analysis of the studies showed similar odds ratios
of norovirus infection among individuals with blood type A (OR = 0.90, 95% CI = 0.71–1.14, P = 0.37), blood type B (OR =
0.85, 95% CI = 0.66–1.12, P = 0.25), and blood type AB (OR = 0.91, 95% CI = 0.60–1.39, P = 0.67), as compared to controls.
An increased odds of norovirus infection was found among individuals with blood type O (OR = 1.28, 95% CI = 1.03–1.59, P =
0.03).

138) Based on the forest plot above, which study had the least influence on the overall pooled effect size for blood type O in
norovirus infections?
A. Tu (2017)
B. Ayouni (2015)
C. Halperin (2008)
D. Rockx (2005)
E. Hutson (2005)

139) Based on this study, what is the overall effect size in terms of increased odds for norovirus infection in those with blood
type O?
A. 3%
B. 14.7%
C. 28%
D. 30%
E. 59%

140) What does the I2 value represent in this meta-analysis?

A. The overall effect size of the intervention across all studies
B. The variation across studies due to heterogeneity rather than chance
C. The confidence interval of the pooled effect estimate
D. The statistical significance of the pooled effect estimate
E. The average quality score of the included studies

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