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LETTER TO EDITOR  
Year : 2018  |  Volume : 43  |  Issue : 2  |  Page : 135
 

Hypothesis generation and testing as an integral component of an outbreak investigation


Department of Community and Family Medicine, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India

Date of Submission19-Jan-2018
Date of Acceptance08-May-2018
Date of Web Publication18-May-2018

Correspondence Address:
Dr. Ajeet Singh Bhadoria
Department of Community and Family Medicine, All India Institute of Medical Sciences, Rishikesh, Uttarakhand
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijcm.IJCM_11_18

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How to cite this article:
Bhadoria AS, Sinha S, Yadav V, Kishore S. Hypothesis generation and testing as an integral component of an outbreak investigation. Indian J Community Med 2018;43:135

How to cite this URL:
Bhadoria AS, Sinha S, Yadav V, Kishore S. Hypothesis generation and testing as an integral component of an outbreak investigation. Indian J Community Med [serial online] 2018 [cited 2019 Jul 21];43:135. Available from: http://www.ijcm.org.in/text.asp?2018/43/2/135/232752




Sir,

Recently published article entitled, “Rapid response to syphilis outbreak among female sex workers” has referred an extremely topical subject of sexually transmitted infections (STIs) among vulnerable population of female sex workers (FSWs) in the country.[1] Furthermore, the evidence that STIs facilitate HIV acquisition and its transmission enhances the seriousness of the problem.[2] Huge burden of STIs has been one of the major driving forces for HIV/AIDS epidemic in India.[3]

However, we have following concerns about this study and intend to highlight here to help readers to be cautious before drawing conclusion.

  1. Authors have aimed to identify risk factors associated with this outbreak. However, suitable statistical analysis for documenting the strength of association has not been detailed. Possibly, root cause analysis (RCA) was carried out to establish risk factors. RCA analysis can document cause and effect model for a problem to take corrective measures, yet it cannot establish association precisely in epidemiological sense. It can complement an outbreak investigation, but it cannot replace the standard outbreak investigation protocol [4]
  2. Result section has well documented the descriptive analysis but completely missed the results of qualitative part (in-depth interview). Fishbone diagram was plotted after RCA analysis but has neither been appropriately labeled in the manuscript nor summarized
  3. The same is true for [Figure 1][1] showing epidemic curve. It has also neither been appropriately labeled in the manuscript nor summarized
  4. Outbreak investigation demands hypothesis testing to establish risk factors. It is a critical step for future prevention of outbreaks. Comparison of variables from FSWs who developed syphilis and those who did not would have yielded important risk factors for this outbreak. Although results of in-depth interview among this group have given an important insight about factors responsible for an outbreak, yet quality of evidence would have been better had quantitative methods been utilized
  5. The sudden upsurge of cases around April as depicted in epidemic curve need to be explained or discussed. Exploration of plausible explanation for this has potential to highlight additional factors.


Unlike to an outbreak investigation, only cases who reported to the facility were investigated, no data were collected from asymptomatic FSWs. Disease follows ice-berg phenomena, and thus ideally, all FSWs from the affected area should have been screened for syphilis for active case finding.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Surti SB, Kosambiya JK, Khokhar N, Patni MM, Gohil AH, Kamdar ZN, et al. Rapid response to syphilis outbreak among female sex workers. Indian J Community Med 2017;42:214-7.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Cohen MS. Classical sexually transmitted diseases drive the spread of HIV-1: Back to the future. J Infect Dis 2012;206:1-2.  Back to cited text no. 2
[PUBMED]    
3.
Prasad TL. An insight into HIV/AIDS epidemic in India and India's response. J NTR Univ Health Sci 2012;1:65-71.  Back to cited text no. 3
  [Full text]  
4.
Palmer SR. Epidemiology in search of infectious diseases: Methods in outbreak investigation. J Epidemiol Community Health 1989;43:311-4.  Back to cited text no. 4
[PUBMED]    




 

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