In-class exercise: Morbidity and mortality data / descriptive epidemiology

An attack rate is an incidence rate, usually expressed as a percent and applied to narrowly defined
populations observed for limited periods of time, as in an epidemic.

Question 1.
In an outbreak involving 26 cases of disease “x”, seven of the cases were found to be female and 19
male. In the group in which the outbreak occurred, there were a total of 9 females and 87 males.
What is the attack rate among the members of each sex and among the group as a whole?

Question 2.
In a city of 212,000 population a total of 1,900 persons died during the year, four from disease y.
what was the crude death rate per 1,000? What was the cause-specific death rate per 100,000?

Question 3.
Multiple sclerosis (MS) has an overall incidence rate in the US of less than one tenth of that of lung
cancer. Yet the prevalence rate of MS is much higher than that of lung cancer (the prevalence of MS
is about 75 cases per 100,000 persons, versus about 40 cases per 100,000 persons for lung
cancer). What is the explanation of this?

Question 4.
Consider a disease X which is not curable. During 1986, a total of 126 cases of disease X were
reported from a community having a population of 20,000. Of the 126 cases, none occurred during
the period January through March, 5 occurred during the period April through June (2 of whom died
in the same period), 113 occurred during July through September ( one of whom died in August and
another in November) and 8 occurred during October through December. Further investigation of
the 126 cases revealed that 67 were males, and of the 4 deaths revealed, that 2 were males. The
number of males in the community is 9,200. The distribution of the total population, the cases and
the deaths from disease X by age groups is presented below. The total number of cases from all
other diseases in the community in the same period is 500, and the total number of deaths from all
other causes is 36.
1- Calculate the incidence rate of disease X during 1986.
2- Calculate the incidence rates per 100,000 population for each of the quarterly period
3- Calculate the sex specific incidence rates per 10,000 population during 1986
4- Determine the ratio of male cases to female cases
5- Calculate the age specific incidence rates per 1,000 population for each of the age groups
shown in the table
6- Calculate point-prevalence on June 30
7- Calculate point prevalence on September 30
8- Calculate period prevalence for the period July through September
9- Calculate the mortality rate for disease X
10- Calculate the age specific mortality rates for the affected age groups
11- Calculate sex specific mortality rates
12- Calculate the case-fatality rate for disease X
13- Calculate the proportionate morbidity rate for disease X
14- Calculate the proportionate mortality ratio for disease X

Age-group (years) Population No. of cases No. of deaths

0-9 3,400 17 2
10-19 4,200 18
20-29 2,800 9
30-39 2,600 11
40+ 7,000 71 2
Total 20,000 126 4
 In-class exercise: Cohort study

Question 1.
The evidence supporting obesity as a risk factor for colon cancer remains inconclusive,
especially among women. A study (Am J Epidemiol 1999;150:390-398) reported the
association between obesity (measured at baseline) and colon cancer morbidity as
determined from review of medical records and death certificates in a nationally
representative cohort of men and women age 25-74 years who participated in the First
National Health and Nutrition Examination Survey from 1971 to 1975 and were
subsequently followed up through 1992. The following table is from this study for men
and women combined.
Baseline Number of incident Population at
body cases of colon cancer risk
mass index*

<22 28 10695

22 - <24 41 7784

24 - <26 36 7322

26 - <28 40 6527

28 - <30 35 4224

30+ 42 6981
* kg body weight per height in meters squared
1. Which research design has been used in this study?
2. Calculate the relative risk (RR) of colon cancer for each of the BMI categories
using the lowest BMI category as referent. Interpret your results
3. Calculate the RR of colon cancer for BMI > 22 (combined) compared to < 22 BMI
category. Interpret the result.

Question 2.
The following data describes the survival experience of five children with acute leukemia:

CHILD Duration of follow-up after Outcome (there is no

diagnosis of leukemia losses to follow-up)
A 3 months Dead
B 9 months Alive
C 1 year and 6 months Dead
D 2 years and 4 months Alive
E 2 years and 8 months Dead

What is the mortality rate (Person Years) in these children?

Question 3.

The following three abstracts summarize the results of epidemiologic studies. For each of
the abstracts:
1) Indicate the study design.
2) Indicate the “exposure/ risk factor” and the “disease/ outcome”
3) Construct one 2x2 table summarizing the results of the study in the following
manner:

Disease
Yes
Exposure No Total

Yes A B a+b

No C D c+d

Total a+c B+d A+b+c+d

4) Based on the 2x2 table, calculate the appropriate measure of association between
the independent variable and the dependent variable.

ABSTRACT 1:
Prevalence of headache among handheld cellular telephone users in Singapore: a
community study.
Chia SE, Chia HP, Tan JS. Environ Health Perspect. 2000 Nov;108(11):1059-62.

We carried out a cross-sectional community study in Singapore to determine the

prevalence of specific central nervous system (CNS) symptoms among hand-held cellular
telephone (HP) users compared to nonusers and to study the association of risk factors
and CNS symptoms among HP users. A total of 808 men and women between 12 and 70
years of age, who lived in one community, were selected using one-stage cluster random
sampling and responses to a structured questionnaire. The prevalence of HP users was
44.8%. Headache was the most prevalent symptom among HP users compared to non-HP
users, with an adjusted prevalence rate ratio of 1.31 [95% confidence interval, 1.00-1.70].
There is a significant increase in the prevalence of headache with increasing duration of
usage (in minutes per day). Prevalence of headache was reduced by more than 20%
among those who used hand-free equipment for their cellular telephones as compared to
those who never use the equipment. The use of HPs is not associated with a significant
increase of CNS symptoms other than headache.
Note: the prevalence of headache among HP users was 60.3%.

ABSTRACT 2:
Cutting birth defects for diabetic moms (In Health, May-June 1991).

San Francisco- Doctors know that children born to diabetic women are 5 times more
likely to have serious birth defects than those with healthy mothers. Now new research
shows that diabetic moms-to-be can reduce this risk by closely controlling the elevated
levels of sugar in their blood before as well as during their pregnancy. University of
California obstetrician John Kitzmiller tracked 194 pregnant diabetics who had
volunteered for an intensive diabetes management program. 84 of the women joined the
program an average of 4 months before they became pregnant; the rest signed up at
least 6 weeks into their pregnancies. Once enrolled, the women checked and adjusted
their blood sugar levels as many as 7 times a day- far more than do most diabetics.
Twelve of the women (11%) who joined the program while pregnant gave birth to infants
with heart deformities or other problems. only one mother from the pregnancy group had
a child with a deformity, the same rate as among healthy women. According to
Kitzmiller, such defects form when a diabetic’s high blood sugar prevents a fetus’s organ
from developing properly during its first 8 weeks – often before a woman even knows
she’s pregnant. By the time she sees her doctor, the damage is done. As a result, says
Kitzmiller, many physicians advise diabetic women not to get pregnant. Instead he says,
the advice should be: Don’t get pregnant unless you’re prepared.

ABSTRACT 3.

High incidence of cardiovascular events in a rheumatoid arthritis cohort not

explained by traditional cardiac risk factors. del Rincon ID, Williams K, Stern MP,
Freeman GL, Escalante A. Arthritis Rheum. 2001 Dec;44(12):2737-45

OBJECTIVE: To compare the incidence of cardiovascular (CV) events in persons with

rheumatoid arthritis (RA) with that in people from the general population, adjusting for
traditional CV risk factors. METHODS: Two hundred thirty-six consecutive patients with
RA were assessed for the 1-year occurrence of 1) CV-related hospitalizations, including
myocardial infarction, stroke or other arterial occlusive events, or arterial
revascularization procedures, or 2) CV deaths. Both outcomes were ascertained by
medical records or death certificates. For comparison, we used CV events that occurred
during an 8-year period among participants in an epidemiologic study of atherosclerosis
and CV disease who were ages 25-65 years at study entry. We calculated the age- and
sex-stratified incidence rate ratio (IRR) of CV events between the 2 cohorts and used
Poisson regression to adjust for age, sex, smoking status, diabetes mellitus,
hypercholesterolemia, systolic blood pressure, and body mass index. RESULTS: Of the
236 RA patients, 234 were observed for 252 patient-years, during which 15 CV events
occurred. Of these, 7 incident events occurred during the 204 patient-years contributed
by patients ages 25-65 years, for an incidence of 3.43 per 100 patient-years. In the
comparison cohort, 4,635 community-dwelling persons were followed up for 33,881
person-years, during which 200 new events occurred, for an incidence of 0.59 per 100
person-years. The age- and sex-adjusted IRR of incident CV events associated with RA
was 3.96 (95% confidence interval [95% CI] 1.86-8.43). After adjusting for CV risk
factors using Poisson regression, the IRR decreased slightly, to 3.17 (95% CI 1.33-
6.36). CONCLUSION: The increased incidence of CV events in RA patients is
independent of traditional CV risk factors. This suggests that additional mechanisms are
responsible for CV disease in RA. Physicians who provide care to individuals with RA
should be aware of their increased risk of CV events and implement appropriate
diagnostic and therapeutic measures.
 In-class 3: Case control
Question 1.
In a case control study to assess the relationship between oral contraceptives
and myocardial infarction the following results were obtained:

Table 1: (Source: Shapiro et al.1979)

Age OC use MI Controls

25-29 Yes 4 62
No 2 224
30-34 Yes 9 33
No 12 390
35-39 Yes 4 26
No 33 330
40-44 Yes 6 9
No 65 362
45-49 Yes 6 5
No 93 301
Total 234 1742

a- Based on the values shown in table1, calculate the appropriate

measure of association between Oral Contraceptive use and
Myocardial infarction (grouping all age groups together). Interpret the
results.
b- At each age interval, calculate the appropriate measure of association
between Oral Contraceptives and Myocardial infarction, interpret the
results.
c- For females with MI who are between 25-29 years of age, what is the
odds of using Oral contraceptives?
d- For Oral contraceptives users of the age group 30-34, what are the
odds of having the outcome?

Question 2

In a study attempting to assess the association between Bladder Cancer and

Yerbamate in Argentina in 2002, a total of 80 cases of Bladder Cancer were
obtained from the Cancer Registry of a major hospital in Argentina. The
researcher selected 80 control subjects from the trauma division of the Hospital.
When assessing exposure, it was noted that 60 of the cases were regular
Yerbamate drinkers compared to half of the controls.

Build a 2*2 table to be able to proceed with the following questions.

a- Calculate the odds of exposure to Yerbamate among Bladder Cancer

cases.
b- Calculate the odds of exposure to Yerbamate among controls.
c- Calculate the Odds Ratio of exposure among cases to controls. Interpret
your results.
 d- Calculate the odds of Bladder Cancer among regular Yerbamate drinkers
and the odds of Bladder Cancer among non-drinkers. Calculate the Odds
Ratio.
e- Suppose that the investigators chose 400 controls instead of 80. Repeat
questions (a) through (d) and comment on the results compared to what
you got in the beginning (Please note that the percentage of exposure
among controls remains unchanged). Why didn’t the odds ratio change in
this case (Hint: what is the formula of OR )

Question 3

The following two abstracts summarize the results of epidemiologic studies. For each of
the abstracts:
4) Indicate the study design.
5) Indicate the “exposure/ risk factor” and the “disease/ outcome”
6) Construct one 2x2 table summarizing the results of the study in the following
manner:

Disease
Yes
Exposure No Total

Yes A B a+b

No C D c+d

Total a+c B+d A+b+c+d

4) Based on the 2x2 table, calculate the appropriate measure of association between
the independent variable and the dependent variable.

ABSTRACT 1

Human papillomavirus infection and oral cancer: A case-control study in

Montreal, Canada. Pintos J, Black MJ, Sadeghi N, Ghadirian P, Zeitouni AG,
Viscidi RP, Herrero R, Coutlee F, Franco EL.Oral Oncol. 2007 Apr 26

The objective of the present study was to examine the association between
human papillomavirus (HPV) infection and risk of developing oral cancer. The
investigation followed a hospital-based case-control design. Cases consisted of
newly diagnosed patients with squamous cell carcinoma of the oral cavity and
oropharynx. Controls were frequency matched to cases on gender, age, and
hospital. Subjects were interviewed to elicit information on putative risk factors.
Oral exfoliated cells were tested for detection of HPV DNA by the PGMY09/11
polymerase chain reaction protocol. Serum antibodies against HPV 16, 18, and
31 viral capsids were detected using an immunoassay technique. Logistic
regression was used to estimate odds ratios (ORs) and 95% confidence
 intervals (CI) of oral cancer according to HPV exposure variables. HPV DNA
was detected in 19% of cases (14 out of 72), and 5% of controls (six out of
129). Among tonsil-related cancers (palatine tonsil and base of tongue) viral
DNA was detected in 43% of cases (nine out of 21). The OR for tonsil-related
cancers for high-risk HPV types was 19.32 (95%CI: 2.3-159.5), after adjustment
for socio-demographic characteristics, tobacco, and alcohol consumption. The
equivalent OR for HPV 16 seropositivity was 31.51 (95%CI: 4.5-219.7). The
ORs of non-tonsillar oral cancers for high risk HPV DNA in oral cells and for
seropositivity were 2.14 (95%CI: 0.4-13.0) and 3.16 (95%CI: 0.8-13.0),
respectively. These results provide evidence supporting a strong causal
association between HPV infection and tonsil-related cancers. The evidence for
an etiologic link is less clear for non-tonsillar oral cancers.

ABSTRACT 2

Hepatitis A in Hispanic children who live along the United States-Mexico

border: the role of international travel and food-borne exposures.
Weinberg M. Hopkins J. Farrington L. Gresham L. Ginsberg M. Bell BP. Pediatrics.
114(1): 68-73, 2004 Jul.

OBJECTIVES: Hispanic children who live along the United States-Mexico border
historically have had among the highest hepatitis A rates in the United States, but
risk factors have not been well characterized. The objective of this study was to
examine risk factors associated with acute hepatitis A virus (HAV) infection in
Hispanic children who live along the United States-Mexico border in San Diego
County, California. METHODS: In this case-control study, hepatitis A cases among
Hispanic children who were younger than 18 years reported from June 1998
through August 2000 were matched by age group and exposure period to Hispanic
children who were susceptible to HAV infection. Participants and their families were
interviewed about demographic information and potential sources of HAV infection,
including attending child care, food and waterborne exposures, cross-border and
other international travel, and travel-related activities. RESULTS: Participants
included 132 children with hepatitis A and 354 control subjects. The median age of
study participants was 7 years (range: 1-17). Sixty-seven percent of case-patients
traveled outside the United States during the incubation period, compared with
25% of the children without hepatitis A (odds ratio [OR]: 6.3; 95% confidence
interval [CI]: 4.0-9.7); all children, except 1, had traveled to Mexico. In multivariate
analysis, hepatitis A was associated with having eaten food from a taco stand or
street food vendor (adjusted OR: 17.0; 95% CI: 4.1-71.1) and having eaten
salad/lettuce (adjusted OR: 5.2; 95% CI: 1.3-20.1) during travel. CONCLUSIONS:
Hepatitis A among Hispanic children who live in an urban area of the United
States-Mexico border is associated with cross-border travel to Mexico and food-
borne exposures during travel. Travelers to areas where hepatitis A is endemic
should receive hepatitis A vaccine before travel.