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# Tutorial Epidemiology for TUTOR

## a. What is the ratio of males to females?

5 Males, 6 Females
Male : Female = 5 : 6
Ratio of males to females is 5 to 6 = 0.83 to 1
b. What proportion of infants lived?
9 lived, 2 died
Proportion lived = lived / all case = 9 / 11 =0 .82
Proportion of infants that lived is 82% or 8.2 out of 11
c. What proportion of infants were delivered in a delivery room?
5 delivery room,
5 operating room,
1 emergency room delivery
Proportion delivery room deliveries = delivery room/ all cases =5/11 = 0.45
Proportion of infants delivered in delivery room is 45% or 4.5 out of 10
d. What is the ratio of operating room deliveries to delivery room deliveries?
5 delivery room and 5 operating room deliveries
delivery room:operating room = 5:5 = 1:1
Ratio of operating room deliveries to delivery room deliveries is 1 to 1.

One thousand men who were working in factory A were screened for HIV on 1 January 2002
and 50 of them were found to be positive for HIV antibodies. The screening was repeated in the
same 1000 men on 1 January 2003 and this time 62 men were positive, including the 50 men
who were positive on the first screening (no one had died or was lost to follow-up).
1. What is the prevalence of HIV in men working in factory A on 1 January 2002, and on 1
January 2003?

2. What is the annual risk of developing HIV infection in men working in factory A in
2002?

One thousand men from factory B were screened for HIV on 1 January 2002 and 50 men were
found to be HIV-positive. All the men were tested for HIV once a month until 31 December
2002. Twelve men became HIV-positive during these 12 months. Figure below shows when
these 12 men became HIV-positive. Tests were always carried out at the end of the month. The
remaining 938 men were still HIV-negative by 31 December 2002. No one died or was lost to
follow-up during this period.
3. What were the odds of becoming infected with HIV in the first 6 months of 2002 in the
12 men who became HIV-positive that year?

4. What is the total number of person-months at risk of HIV infection observed in this
study?

## 5. What is the incidence rate of HIV infection in men working in factory B?

6. Assume that we begin a study of 100 persons free of disease on January 1, and that on the
last day of each month throughout the year, we will be given a count of new cases of
disease in this population. Assume that over the course of a full year, 10 of these persons
develop disease, and that 2 of these cases were reported on March 31, 3 more cases on
June 30, 3 cases on September 30, and 2 cases on December 31. How many personmonths did the study members contribute (assume patients became cases on the last day
of the month).

## (90 patients x 12 months) + (2 patient x 3 months) + (3 patients x 6 months) + (3 patients

x 9 months) + (2 patients x 12 months) = 1155 person/month
7. If we wanted to obtain a measure of the incidence of breast cancer among women in
North during 1997, what breast cancer cases would we count in the numerator?
a. All cases of breast cancer among women in North in 1997
b. Only newly diagnosed cases of breast cancer among women in North in 1997?
8. Assuming that we begin to measure incidence on January 1, 1997, which North women
would be counted for the denominator of the incidence measure?
a. All women in North in 1997.
b. Only women in North without breast cancer on January 1, 1997.
9. To measure the prevalence of breast cancer among women in North for the year 1997,
what breast cancer cases would we count in the numerator?
a. All breast cancer cases reported to the North Cancer Registry in 1997
b. All breast cancer cases ever reported to the North Cancer Registry
c. All surviving breast cancer cases ever reported to the North Cancer Registry
A study followed a population of 2000 women aged over 65 years for 10 years and measured
the number of cases of osteoporosis diagnosed during that time period. The investigators
were interested in the effect of regular exercise on the development of osteoporosis and
divided the women into two groups: 1000 women who took regular exercise (exposed) and
1000 women who did not take regular exercise (unexposed). The investigators recorded 800
new cases of osteoporosis over the 10 years of the study, 300 in those who took regular
exercise and 500 in those who did not. The number of person-years at risk was 8350 in the
exposed group and 6950 in the unexposed group.
10. Calculate the risk ratio, and rate ratio for the effect of regular exercise on osteoporosis in
these women.
To calculate the risk ratio, first work out the incidence of osteoporosis in the older women
who took exercise and in those who did not:
Incidence in women who took regular exercise = 300 / 1000 = 0.3 per 10 years.
Incidence in women who took no regular exercise = 500 / 1000 = 0.5 per 10 years.
Then divide the incidence in the exposed group by the incidence in the unexposed group:

This indicates that women aged over 65 years who take regular exercise have a 40%
lower risk of developing osteoporosis than women who do not take regular exercise.
To calculate the rate ratio, work out the rate of osteoporosis in women who took exercise
and in those who did not take regular exercise:
Rate in women who took regular exercise = 300 / 8350 person-years = 0.036 per personyear = 3.6 per 100 person-years.
Rate in women who did not take regular exercise = 500 / 6950 person-years = 0.072 per
person-year = 7.2 per 100 person-years.

Therefore, women aged over 65 years who take regular exercise have a 50% lower rate of
osteoporosis than women who do not take regular exercise
In this case, the rate ratio is probably the most appropriate measure since it takes into
account the person-years at risk in the exposed and unexposed groups.
The investigators then decided to do another study to look at osteoporosis in women aged
less than 55 years. Again they followed 1000 women who took regular exercise and 1000
women who did not for 10 years. This time they recorded 3 cases of osteoporosis in those
who took exercise and 5 cases in those who did not. The number of person-years at risk was
9500 in the exposed group and 9000 in the unexposed group.
11. Calculate the risk ratio, and rate ratio for the effect of regular exercise on osteoporosis in
these younger women.
Now for the calculations in younger women, starting with the risk ratio:
Incidence in women who took regular exercise = 3/1000 = 0.003 per 10 years.
Incidence in women who took no regular exercise = 5/1000 = 0.005 per 10 years.
Then divide the incidence in the exposed group by the incidence in the unexposed group:

This indicates that women aged less than 55 years who take regular exercise have a 40%
lower risk of developing osteoporosis than women who do not take regular exercise.
To calculate the rate ratio, work out the rate of osteoporosis in women who took exercise
and in those who did not take regular exercise:
Rate in women who took regular exercise = 3/9500 person-years = 0.00032 per personyear = 3.2 per 10,000 person-years.
Rate in women who did not take regular exercise = 5/9000 person-years = 0.00056
per person-year = 5.6 per 10,000 person-years.

Therefore, women aged less than 55 years who take regular exercise have a 43% lower
rate of developing steoporosis than women who do not take regular exercise.
Suppose that a case-control study was conducted to evaluate the relationship between
artificial sweeteners and bladder cancer. 3,000 cases and 3,000 controls were enrolled in the
study. Among the cases, 1293 had used artificial sweeteners in the past, while 1707 had never
used artificial sweeteners. Of the controls, 855 had used sweeteners and 2145 had not.
12. Set up the two by two table for these data.

13. What measure of association/comparison should be used to assess the strength of the
relationship between artificial sweeteners and bladder cancer?
Odds ratio (OR)
14. Calculate this measure.
OR = ad/bc= (1293)(2145) / (855)(1707)= 1.9
15. Interpret the result in one sentence.
People who use artificial sweeteners are 1.9 times more likely to develop bladder
cancer than those who do not use sweeteners
Compute the odds ratio by category of daily cigarette consumption, comparing each smoking
category to nonsmokers
Daily number
Number of cases Number of
Odds Ratio
of cigarettes
control
0
7
61
Referent (7 x 61) / (61 x 7) = 1
1 14
565
706
(565 x 61) / (706 x 7)
15 24
445
408
(445 x 61) / (408 x 7)
25 +
340
182
(340 x 61) / (182 x 7)
All smokers
1350
1296
(1350 x 61) / (1296 x 7)
Total
1,357
1357

A hypothetical study of the effect of alcohol intake on the risk of gallstones in MexicanAmericans aged 20-74 was conducted. Ultrasonography of the gallbladder of 2200 study subjects
identified 152 subjects with gallstones, 42 of whom listed their alcohol consumption level as
"high". Of the men without gallstones, 220 listed their alcohol intake level as "high". Interviews
were conducted at the same time as the examinations to determine the exposure level of study
participants.
16. Which measure of association is most appropriate in this cross-sectional design?
a. Prevalence ratio
b. Prevalence odds ratio
c. Cumulative incidence
d. None of the above

The prevalence odds ratio (POR) is the correct measure of association because POR is
preferred in studies of chronic diseases or studies of long-lasting risk factors, such as
alcohol intake.
Explanation of other choices:
a. Incorrect. The PR is calculated when the outcome occurs over a short time, such as an
acute outbreak of an infectious disease. Gallstones develop more slowly, so the POR
would be more appropriate.
c. Incorrect. The cumulative incidence (CI) is a measure of association that can only be
calculated from a cohort study. It requires a count of total new cases of a disease divided
by the population at risk. This is not possible from a cross-sectional study since subjects
are not observed over time.
d. Incorrect.
17. For which of the following disease situations could a cross-sectional study design be used
to determine prevalence?
a. Disease w, a highly fatal disease in which the average length of survival after diagnosis
is approximately one month.
b. Disease x, a disease with a long latency period where infection is identifiable by a
serological test.
c. Disease y, a disease which is caused by a chromosomal malformation present at birth
(or before).
d. Both b and c
Correct answer: d. Both b and c are situations in which a cross-sectional study design
could be used to determine a measure of prevalence. Prevalence can be determined if a
disease has a long latency period that can be detected through a serological test. In choice
c, the duration of disease is not affected by exposure. The condition is due to a
chromosomal malformation, and will be present throughout life regardless of how long a
person was exposed. Prevalence is often used to describe conditions that are permanent,
and present at birth, such as congenital malformations.
Explanation of other choices: a. Incorrect. In this situation, highly fatal cases would not
be represented in a measure of prevalence since many people with the disease may have
died before the questionnaire was administered. Prevalence is not an accurate measure
when a disease is highly fatal