Module Tittle: Epidemiology, Biostatistics and Research Methods

Faculty: Dr. Pratap Kumar Jena

Program: Master of Hospital Administration (MHA)
Student Name: Rockson Ohene Asante
Roll Number: 2235026
Nature of Work: Assignment

AUTUMN END SEMESTER EXAMINATION SOLUTIONS 2017.

1 a) Descriptive epidemiology is the branch of epidemiology which describes

health related events or states or diseases in term of population affected (who),
the place or geographical location (where) and the time of occurrence (when).
Descriptive epidemiology does not answer the question why such an event is
occurring.
b) Secondary attack rate is defined as an attack rate in susceptible people who
were not directly exposed to the suspected agent but have been exposed to a
primary case. In computing secondary attack rate, the numerator involves the
number of people who have been exposed to the primary case who get the
disease and the denominator includes the total number of people exposed to the
primary case.
Secondary Attack Rate = number of people who have been exposed to a
primary case who become ill

Total number of people who have been exposed to the

primary case
c) Point source epidemics involve a common source, such as contaminated
food or an infected food handler, and all the exposures tend to occur at once. In
point source epidemics, all cases tend to fall within one incubation period and
tend to have epidemic curves with a rapid increase in cases followed by a
somewhat slower decline.
d) Why John Snow is famous in Epidemiology.
In 1854, John Snow did a series of investigations and he made great contribution
in epidemiology that warranted his being considered the father of field
epidemiology. One of his famous investigation he did in 1854, he looked for a
relationship between the distribution of households in golden square area in
London with cases of cholera and the location of water pumps.

2: Cohort study, in cohort study, the participants are selected based on the
exposure status, some of the participants may have the exposure and others do not
have the exposure at the time of initiation of the study, then both the exposed and
unexposed participants are followed over time to evaluate for the occurrence of
outcome of interest. The outcome may either develop or do not develop in the two
groups.
In analysis of cohort study, the parameters used are the two groups (exposed and
unexposed groups) and rates of outcome of interest (incidence rates) are measured
and compared in the two groups.

3: The basic steps in conducting controlled clinical trial

Phase I trials: This step involves small number of subjects ranging from 20 to 80
patients. The purpose is look for safety and dosage issues. Toxic and
pharmacologic effects are examined, including safety, safe ranges of human
dosage, and the side effects. If the drug passes these studies, it then undergoes
phase II studies.
Phase II trials: this phase consist of clinical investigations of 100 to 300 patients
in order to evaluate the efficacy of a drug and to further assess its relative safety.
If the drug passes phase II studies, it is then tested in phase III trials.
Phase III trials: These studies are large-scale randomized controlled trials for
efficacy and relative safety. These studies often include 1,000 to 3,000 or more
participants. If the drug passes phase III testing, it can be approved and licensed
for marketing.
Phase IV studies: Phase IV studies, are also called post-marketing surveillance,
which involve continuous monitoring of new drugs as they are into general use by
the public. It is possible that the new drug may have adverse effects that they may
not be detectable even in relatively large randomized clinical trials, but may
become evident only when the drug is in use by large populations after marketing
has begun. These adverse effects can be detected by performing post marketing
surveillance.
Blinding is the method used to avoid bias in clinical trials whereby either only
participants (single blinding) or both participants and the data investigators
(double blinding) are unaware of the type of treatment they receive.

4: a) Surveillance is an ongoing systemic collection, analysis and interpretation of

health related data and dissemination of information to those who can take
actions such policy makers, this information forms a basis for development of
public preventive or health promotion measures.
b) Sensitivity: is the ability of the test to correctly detect individuals who have
the disease, but specificity is the ability of the test to identify correctly those who
do not have the disease.
AUTUMN END SEMESTER EXAMNATION SOLUTIONS 2018.
1 a) Direct standardization, is one of the methods that aids the comparison of
rates of events or the mortality rates between two groups or populations. It is
used when the mortality rates in each age group in both study populations are
known. In epidemiological research, direct standardization is used to overcome
the effect of confounders.
b) The denominator in calculating secondary attack rate is the total number of
people who have been exposed to the primary case.
c) The type of study that will help to calculate incidence rate is cohort study
d) The study used to compare diseased and non-diseased individuals is
casecontrol study
e) Consider the 2X2 (contingency) table below

Renal cell carcinoma status Total

Diseased Not diseased

Smoking Smokers 30 10 40
status
Non smokers 20 40 60

Total 50 50 100

Odds ratio = odds of disease in smokers/odds on disease in non-smokers

=ad/bc =30*40/10*20 = 6
Therefore, odds ratio of renal cancer associated to smoking is 6, this implies that
the risk for developing renal cancer in smokers is greater than that in non-
smokers.

3) Descriptive studies are useful for estimating the burden of diseases in the
population, for example they can be used to estimate prevalence of cataract in a
particular city.
The indications of descriptive studies are;
I. To describe an event in relation to time, place and population.
II. To measure the burden of diseases in the population
The advantages of descriptive studies: they are simple to conduct and are
inexpensive. Also descriptive studies are helpful in generation of hypothesis. The
measures of association in descriptive studies like cross-sectional studies, include
prevalence odds ratio (POR) when prevalent cases are included, and the prevalence
ratio (PR). These measures of association can be calculated to compare the number
of events in two populations.

4 a) Surveillance is a systematic ongoing collection, collation, and analysis of data

and the timely dissemination of information to those who need to know so that
action can be taken. In non-communicable diseases (NCD) surveillance helps to
establish baseline rate of disease and detect increases, estimate magnitude of a
non-communication and determine their geographic distribution where
appropriate interventions are implemented.

5. a) P-value can be defined as the probability that the observed result is due to
chance alone. The p value tells us whether what we have observed in the study is
statistically significant. The interpretation of p values is based on reference to a
particular level of significance which is conventionally set at 0.05. Hence p values
less than this number are significant while those above are not.
Confidence interval is the range of values within which we are reasonably confident
that the population parameter lies. Alternatively, we can say that we are 95%
confident that the true population value of what we are estimating in our study lies
within the interval. The most commonly reported interval is the 95% confidence
interval.
P-values and confidence intervals (CI) are used in almost all scientific writings for
interpreting results of statistical analysis.
 6. Mean is the average of all values in a given sets of data, also it can be defined
as the total number of observation divided by number of observations.
For example, consider the given set of values {6, 7, 6, 9, and 8}
Mean = (6+7+6+9+8)/5 =7.2
Mode is the most frequent occurring value in the given set of data. For example,
the mode in the given numbers above is 6, because it is repeated two times. Median
is the middle number of a set of numbers arranged in numerical order, the median
in the above values is 7.

7 a) Hill’s criterion for causation

i. Biological plausibility: this criterion implies that epidemiology and biology

must interact. Plausibility is judged based on the presence of existing biological
or social models that explain the association of interest. The criterion of
plausibility is satisfied if the relationship is consistent with the current body of
knowledge regarding the aetiology and mechanism of disease.

ii. Consistency criterion: this is upheld when multiple epidemiologic studies

using a variety of locations, populations, and methods show a consistent
association between two variables with respect to the null hypothesis. Hill
stressed the importance of repetitive findings because a single study, no matter
how statistically sound, cannot be relied upon to prove causation due to ever-
present threats to internal validity.

iii. Strength of association. Hill explained that, the larger an association between
exposure and outcome (disease), the more likely it is to be causal.

7. b) Sensitivity: is the ability of the test to correctly detect individuals who have
the disease, but specificity is the ability of the test to identify correctly those who
do not have the disease.
AUTUMN END SEMESTER EXAMNATION SOLUTIONS 2019.
1. a) The answer is D
b) The answer is A
c) The answer is A
d) The answer is B, because relative risk can be calculated in case-control
e) The answer is D, solution for this is given below,
Incidence in exposed (IE) = 5X
Incidence in unexposed (IU) =X
Therefore, from the formula, Attributable Risk Fraction (ARF)=IE-IU/IU*100%
= 5X-X/X*100% =80%

3. Disease control is an ongoing operations aimed at reducing the incidence of

disease, the duration of disease and consequently the risk of transmission as well
as the effects of infection. The following are the steps of disease control and their
examples:
Primordial prevention
: refers to avoiding the development of risk factors in the first place. Example:
community based program to increase physical activities, reduce sodium in food
supply
Primary Prevention: the action taken prior to the onset of disease which removes
the possibility that the disease will ever occur. Example: infection control,
immunization, sanitation
Secondary prevention: are actions which halts the progress of a disease at its
early stage and prevent complications. It is largely the domain of clinical
medicine.
Example: screening tests, case finding programs.
Tertiary prevention; it is used when the disease process has advanced beyond its
early stages. It involves all measures available to reduce or limit impairments and
disabilities, and to promote patients' adjustment to irremediable conditions.
Example: Interventions such as disability limitation and rehabilitation
Elimination of infection is the reduction to zero of the incidence of infection
caused by a specific agent in a defined geographical area as a result of deliberate
efforts; continued measures to prevent re-establishment of transmission are
required. Example: measles, poliomyelitis, while eradication of infections is a
permanent reduction to zero of the worldwide incidence of infection caused by a
specific agent as a result of deliberate efforts; intervention measures are no
longer needed. Example: smallpox.

4. a) Direct standardization is one of the methods that aids the comparison of

rates of events or the mortality rates between two groups or populations. It is
used when the mortality rates in each age group in both study populations are
known. In epidemiological research, direct standardization is used to overcome
the effect of confounders.
b) Positive predictive value is the ratio of subjects truly diagnosed as positive to
all those who had positive test results.

5. Natural history of disease is defined as the progression of disease in an

individual in absence of treatments. The natural history of a disease is classified
into five stages: underlying, susceptible, subclinical, clinical, and
recovery/disability/death. Corresponding preventive health measures have been
grouped into similar stages to target the prevention of these stages of a disease.
The preventive stages are primordial prevention, primary prevention, secondary
prevention, and tertiary prevention. Understanding the natural history of diseases
is important because, it enable public health professionals to develop appropriate
strategies not only aim to prevent the onset of disease through risk reduction, but
also downstream complications of a manifested disease.
 6. An infectious agent may be transmitted from its natural reservoir to a
susceptible host in different ways. There are different classifications for modes of
transmission which broadly are categorized as direct or indirect transmission.
Here are explained in detail:
1. Direct transmission
In this mode, an infectious agent can be transmitted either through direct contact
or droplets spread.
I. Direct contact occurs through skin-to-skin contact example scabies, kissing like
oral candidiasis, and sexual intercourse like HIV and gonorrhoea. Direct contact
also refers to contact with soil for example tetanus or vegetation harbouring
infectious organisms.
II. Droplets spread refers to spray with relatively large, short-range aerosols
produced by sneezing, coughing, or even talking. Droplet spread is classified as
direct because transmission is by direct spray over a few feet, before the
droplets fall to the ground. Pertussis and meningococcal infection are examples
of diseases transmitted from an infectious patient to a susceptible host by
droplets spread.
2. Indirect transmission refers to the transfer of an infectious agent from a reservoir
to a host by suspended air particles, inanimate objects (vehicles), or animate
intermediaries (vectors).
I. Airborne transmission occurs when infectious agents are carried by dust or
droplet nuclei suspended in air. Airborne dust includes material that has settled
on surfaces and become suspended by air currents as well as infectious particles
blown from the soil by the wind. Droplet nuclei are dried residue of less than 5
microns in size. In contrast to droplets that fall to the ground within a few feet,
droplet nuclei may remain suspended in the air for long periods of time and
may be blown over great distances, for example, Measles
II. Vehicles that may indirectly transmit an infectious agent include food, water,
biologic products (blood), and fomites (inanimate objects like handkerchiefs,
bedding, or surgical scalpels).
 A vehicle may passively carry a pathogen to susceptible individuals, for example
hepatitis A virus infection. Alternatively, the vehicle may provide an environment
in which the agent grows, multiplies, or produces toxin, like improperly canned
foods may provide an environment that supports production of botulinum toxin
by Clostridium botulinum.
III. Vectors such as mosquitoes, fleas, and ticks may carry an infectious agent
through purely mechanical means or may support growth or changes in the
agent. Examples of mechanical transmission are flies carrying Shigella on their
appendages and fleas carrying Yersinia pestis, the causative agent of plague,
in their gut.

7. a) Difference between association and causation

Association explores if a specified health outcome is more likely in people with a
particular exposure, or alternatively, is there a link between a particular exposure
with an outcome of interest. Association is a statistical relationship between two
variables. Two variables may be associated without a causal relationship. For
example, people of lower socioeconomic status have a higher risk of lung cancer,
i.e., there is a clear association. However, there is obviously no causal relationship.
While causation means that the exposure produces the effect. For example, it is
known that tobacco smoking is associated with lung cancer, causation theory tries
to explore what exactly in tobacco causes lung cancer. A cause must be associated
with the outcome, but simply demonstrating an association is not enough. For
example, concluding that lack of exercise is a cause of heart disease, one needs to
review the body of evidence suggesting a causal relationship among these two
variable and also consider other criteria. For example,

• Does exposure to tobacco smoke and precede the occurrence of lung cancer?
• Is there a strong association between smoking and subsequent occurrence of
lung cancer?
 b) Criteria for causation
I. Strength of the association.
According to Hill, the stronger the association between a risk factor and
outcome, the more likely the relationship is to be causal.
II. Consistency of findings.
Hill’s emphasized that if there are same findings observed among different
populations, in different study designs and different times, then the exposure
is said to causal.
III. Coherence.
Does the relationship agree with the current knowledge of the natural
history/biology of the disease? If this is true, then the exposure is said to
causal.