Epidemiology Final Notes

Week 1 Content
- Epidemiology: study of what is upon the people/ the study of the distribution and
determinants of health-related states or events in specified populations and the
application of control of health problems
- Etiology: cause of disease
- Determinants: Factors or events that bring about a change in health status
- Biologic agents: bacteria, Chemical: carcinogens/lead/arsenic, Lifestyle: stress
- Top 3 causes of death in 20th century-> infectious diseases (TB, diarrhea,
pneumonia, flu)
- Top 3 causes of death in 21st century-> chronic diseases (heart, cancer, stroke)
- Primary prevention
- Preventing the initial development of a disease-> Vaccines
- Secondary prevention
- Early detection/screenings
- No S/S
- Tertiary prevention
- Reducing the impact of the disease-> rehabilitation
- Ignaz Semmelweis
- Childbed fever/ puerperal fever
- Handwashing of physicians vs midwives (midwives were found to have better
hand hygiene)
- Edward Jenner
- Smallpox / cow pox and milk maids
- vaccines-> vacca=cow
- Robert Koch
- Demonstrated the associated between a microorganism and a disease
- John Snow
- Cholera outbreak in london
- Father of epi
- William Farr
- registrar general
- miasmatic theory of disease- disease was transmitted by a cloud
Week 2 Content
- Modes of transmission
- Direct: person to person
- Indirect: common vehicle (air, vector, water)
- Host- humans, animals, demographics
- Agents- bacteria, viruses, alcohol
- Environment- crowding, housing, food, geography
-
- Prognosis: a prediction of the course of a disease
- some diseases are more severe and lethal than others
- quantify the baseline of the natural history of a disease
- Clinical Disease
- Signs and symptoms
- Nonclinical disease
- Preclinical: progress to clinical
- subclinical: will not progress to clinical disease
- Persist: chronic disease (polio, chickenpox)
- Latent: typhoid mary
- Endemic: habitual presence of disease
- Epidemic: excess occurrence of disease than normal
- Pandemic: epidemic that spreads world-wide
- Outbreak types: 1) exposure 2) single exposure, common vehicle outbreak
- Exposure: single -exposure,common vehicle outbreak: epi curve= incubation period
- Herd immunity: Resistance of a group of people to an attack by a disease to which a
large portion of the population are immune
- Epidemiology Curve: A visual display of the onset of illness among cases associated
with an outbreak.
- aka: incubation period
 - Incubation period
- The interval from receipt of infection to the time of onset of clinical illness
- No sign of disease
- Attack rate
- Aka Incidence rate
- Useful in comparing risk of disease in groups with different exposures
- # of people at risk with an illness divided by the total number of people at risk
Week 3 Content
- Ratio: relationship of two numbers
- Rate: a comparison of measurements that have different units; special ratio
- Unit rate: a rate with a denominator of 1
- Proportion: an equation that says that two or more ratios are equal
- X is to y as a is to b
- The products xb and ay are called cross products
- The cross products are always equal
- Morbidity: measures of illness
- Rate: indicates how fast the disease is occuring in a population
- Proportion: tells us what fraction of the population is affected
- Cumulative Incidence Rate
- # of new cases over a specified period of time divided by # of total population at
risk
- Incidence rate/density
- # of new cases during a specified period of time divided by total # of person-time
when at risk
- EX: Five new cases of HIV were reported. This brings the total number of HIV
cases this year to 56. Total population is 100,000 and population at risk of HIV is
20,000.
- 20,000 x 0.5 y/p= 10,000 person-years -> IR= 5/10,000
- Prevalence Rate
- P= number of cases divided by number in whole population
- EX: 56 active cases of HIV / 100,000 total population
- 56 per 100,000
- Prevalence rates are increased by 1) an increase in the number of new cases
and 2) a reduction in deaths due to a disease
- Inc incidence = inc prevalence
- Inc duration = inc prevalence
- Surveillance: Ongoing to systematic collection analysis and interpretation of health data
essential to the planning and implementation and evaluation of public health practice
closely integrated with the timely dissemination of the data to those who need to know
- Passive: no additional funding; available data from providers (lead poisoning)
- Active: expensive; staff are hired to collect mandated data (hiv/aids)

Week 4 Content
- Mortality Rate: risk of disease and dying
 - Mortality rate= (total # of deaths from a disease divided by # of persons in the
population at midyear ) multiplied by per 100,000 population or per 1,000
population
- Case-Fatality Rate: % of people who have a certain disease die within a certain time
after that disease was diagnosed
- CFR= (# of people dying during a specified period of time after disease onset
divided by # of people with specified disease) multiplied by 100
- Difference between mortality and case fatality: mortality deals with the entire
population at risk of dying from the disease whereas case fatality is limited to people who
already have the disease
- Proportionate Mortality: (# of deaths from a disease divided by total deaths) multiplied
by 100
- Years of Potential life lost: measure of premature mortality
- Subtract age of death from 65

Week 5 Content
- Validity: the ability of the test to distinguish between who has the disease or not
- Specificity: the proportion of non-diseased people who were correctly identified as
negative by the test
- Specificity= true negative divided by (true negative plus false positive)
- Sensitivity: the proportion of disease people who were correctly identified as positive by
the test
- High cut off level
- sensitivity= true positive divided by (true positive plus false negative)
- Positive Predictive Value: the proportion who tested positive who have the disease
- Low cut off level
- PPV= true positive divided by (true positive plus false positive)
- Negative predictive value: the proportion who tested negative who do not have the
disease
- NPV= true negative divided by (true negative plus false negative)
- False Positive: test positive but do not have the disease
- False negative: test negative but do have the disease
-

- Sequential testing: two stage screening

- Dec net sensitivity, inc net specificity
- Retest only those that tested positive
- Prognosis: natural history of a disease/ duration of disease from diagnosis
- Expressed as # of deaths or survivors with the disease
- Reliability:is the test repeatable?
- factors: intrasubject variation, intraobserver variation, interobserver variation
- Intrasubject variation: Variation within individual subjects
- Example: blood pressure
 - Intraobserver variation:Variation in the reading of the test results by the same reader
- example: x-rays
- Interobserver variation: Variation between those reading the test results

Week 8 Content
- Case Reports: individual-level observations documentation
- Describes a particular clinical phenomenon in a single patient
- Case Series: describes more than one patient with similar problems
- Association:
- Causation:
- Direction of Relationship:
- Association: A relationship exists but does not indicate direction (i.e., which variable is
affecting which).
- Causation: There is a clear direction, with one variable directly influencing the other.
- Control of Variables:
- Association: Often observed through correlation or pattern analysis without controlling other
variables.
- Causation: Determined through controlled experiments or studies where other variables are
held constant.
- Evidence Required:
- Association: Can be observed through data analysis and statistical tests, such as correlation
coefficients.
- Causation: Requires more rigorous evidence, often from experimental studies or longitudinal
studies with controls, replication, and theoretical backing.
- Examples:
- Association: Higher levels of education are associated with higher income. This doesn’t mean
that more education directly causes higher income, though education often does lead to
better job opportunities.
- Causation: Vaccines cause immunity against certain diseases. Here, the direct cause-and-effect
relationship is established through extensive research and testing.

- Ecological Studies: a study of group characteristics that can help explore associations
- Ecologic Fallacy: ascribing to members of a group some characteristic that they do not possess
as individuals
- Observational Study Designs
- Cross sectional study
- Cohort study
- Advantages: directly estimates disease incidence and risk & determines temporal
Relationship between exposure & disease
- Disadvantages: expensive, exposure may take years after study begins, bias
- Case-control study
- Cross Sectional Study = Prevalence study
- Present: disease and exposure
- Cannot form a temporal association between exposure and disease outcome
- Snapshot of population or slice through time
- Prevalent cases (no duration info)
- Cohort Study
- Present: exposure future: disease
- Prospective study
- Framingham Study
 - Concurrent cohort/ longitudinal study
- Investigator identifies the original population at the beginning of the study and follows up
until Disease is developed or not
- Exposure is ascertained as they occur
- Retrospective study
- Historical cohort study
- Non Concurrent prospective cohort
- Use historical data to speed up results
- EX: breast cancer and progesterone deficiency cowan et al.
- Case-Control Study = Retrospective study
- Present: disease and past: exposure
- Determine the proportion of cases and controls exposed and not exposed
- The prevalent of history of exposure should be higher in cases than controls
- EX: smoking = lung cancer
- Cases: patients, registries, tertiary care
- Controls: Can choose any ratio to compare cases, must be careful and take prevalence into
account
- Data Sources:
- Matching: aim to match cases and controls based on exposure, SES, other factors
- Group: proportion of controls with characteristic is identical to cases
- Individual: matches pairs, cases individually matched to a control (hospital)
- Recall Bias: data collection via interviews
- Differential recall between cases and controls can introduce recall bias
- Sir Richard Doll
- Study about lung cancer and connection to smoking

Week 9 Content
- Clinical Randomized Trials History
- Considered the ideal design for evaluating both the effectiveness and the s/e of new form
Of intervention
- Gold standard
- Blind: subjects don't know what group they are in/ placebo
- Double Blinding: observers are blind to subject’s group assignment
- Crossover
- Planned: subjects are randomized to new or current treatment and observed
- Switched to other treatment and observed
- Ea. pt serves as their own control
- Drawbacks: treatment residuals, surgical treatment
- Unplanned: randomized after informed consent, subjects can opt to switch
- Analyze pts based on original assignment after randomization
- Must be kept to a minimum
- Noncompliance:
- Drop in: subjects may overtly or covertly not participate in the study, checks
built in
- Drop out:controls may take medication on treatment side, checks built in
- External Validity: generalizability
- Internal Validity: study is done without major methodologic problems and takes into
account all issues
- Phases I: Clinical pharmacologic studies looking at toxic and pharmacologic effects
- Phase 2: Clinical investigations of 100 to 200 patients looking at efficacy and safety
- Phase 3: Large scale and randomized controlled trials for effectiveness and safety/
 Licensed for marketing
- Phase 4: Post marketing surveillance/Carcinogenesis/ teratogenesis
- Ambroise Paré
- Unplanned trial
- Abolished practice of pouring boiling oil on wounds to sterilize them
- Improved surgical techniques
- Father of military medicine and modern surgery
- James Lind
- Planned trial
- Conqueror of scurvy-> dietary cause of disease; lack of vitamin c
- Experiments on cases
- Selection of Subjects
- Selection criteria must be precisely written
- Historical Controls
- Comparison gorup from the past
- Compare same disease with old tx outcomes
- Trouble with data abstraction
- Difference in outcomes d/t therapy, data, time, lifestyle, nutrition
- Simultaneous Non Randomized Controls
- Assign controls by even/odd day of the month
- Envelopes: predictable assignment will introduce selection bias

Week 10 Content
- Absolute Risk: Incidence of a disease in a population
- Can indicate the magnitude of the risk in a group of people with certain exposure
- It does not take into account the risk of disease and non-exposed individuals
- It does not indicate whether the exposure is associated with an increased risk of disease
- Implicit comparison is made when looking at the incidence of the disease
- To measure association must use an explicit comparison
- Relative Risk: What is the ratio of the risk of disease and expose individuals to the risk of
disease and non exposed individuals
- Etilogical relationship
- RR= 1 Risk exposed = Risk unexposed No association
- RR>1 Risk exposed > Risk unexposed + Association
- RR < 1 Risk exposed < risk unexposed - association
- Odds Ratio (Relative Odds): odds that an exposed person develops disease odds that a non
exposed person develops disease
-from a cohort or case-control study
 - OR= 1 no association
- OR > 1 + association
- OR < 1 - association
- Case-control study
- know diseased, measure exposure, incidence not known
- Not randomized due to ethics
- You have a control group
- Cohort study
- Know exposed, measure diseased
- Matched Pairs: B/C
- ADD PICTURE FROM BOOK
- Concordant Pairs: case-control pairs that had the same exposure experience
- Pairs in which both the case and control were exposed
- Pairs in which neither the case nor the control was exposed
- Discordant Pairs: different exposure experience
- Pairs in which the case was exposed but the control was not
- Pairs in which the control was exposed but the case was not
- Attributable Risk: the amount of or proportion of disease incidents(disease risk) that can be
attributed to a specific exposure
- Addresses the clinical and public health issues
 -
- Population Attributable Risk

-
- Background Risk
- Every person shares regardless of whether or not he or she has had the specific exposure
In question
- unexposed and exposed persons have this
- Associations
- Real: true
- Spurious: false
- Causation:
- Direct: a factor directly causes a disease without any intermediate step
- Indirect: A factor directly causes a disease only through an intermediate step
- Confounding: Permits us to identify people who are at a higher risk for the disease and
direct appropriate preventative and therapeutic interventions to them
-helpful in screening populations
- Human Studies Sequence: clinical observations, available data, case-control studies, cohort
Studies, randomized trials
- Unplanned or natural experiments:A measure of exposures in an individuals (non study purpose)
versus non-exposed
- Determine Whether there is an increased risk of a certain adverse effect in persons
who have been exposed
- Occupational, toxic exposures, chernobyl or atomic bomb
- Bias: Any systematic error in the design conduct or analysis of a study that results in a mistaken
estimate of an exposure’s affect on the risk of disease
- Information bias: Obtaining information about the subjects in the study are inadequate so
that as a result some of the information gathered regarding exposures and or disease
outcome is incorrect
- Surveillance bias: Leads to an erroneous estimate of the relative risk or odds ratio
- Selection bias:Non-response of potential study subjects

Chapter Questions
Chapter 2
1. Endemic means that a disease: b. Is habitually present in human populations
2. Ate Food Items
Ate egg salad: 75 (ate tuna) 100 (did not eat tuna)
Did not eat egg salad: 200 (ate tuna) 50 (did not)
-Who Later Became Sick (with Acute Sore Throats)
Ate egg salad 60 (ate tuna) 75 (did not)
Did not eat egg salad 70 (ate tuna) 15 (did not)
- What is the sore throat attack rate in persons who ate both egg salad and tuna?*️a- 60/75
3. According to the results shown in the preceding tables (tuna and egg salad question stem),
which of the following food items (or combination of food items) is most likely to be infectious? B- egg Salad
only
4. In the study of an outbreak of an infectious disease, plotting an epidemic curve is useful because:
D- It helps to determine what type of outbreak (e.g., single-source, person-to-person) has
Occurred & It helps to determine the median incubation period
5. Which of the following is characteristic of a single-exposure, common-vehicle outbreak?
C- explosive
6. Which of the following recent widespread diseases is considered pandemic?
C - H1N1 flu virus- swine flu

Chapter 3
1. 1. At an initial examination in Oxford, Mass., migraine headache was found in 5 of 1,000 men
aged 30 to 35 years and in 10 of 1,000 women aged 30 to 35 years. The inference that
women have a two times greater risk of developing migraine headache than do men in this
age group is:
E- incorrect, because of failure to distinguish between incidence and prevalence
2. A prevalence survey conducted from January 1 through December 31, 2012, identified
1,000 cases of schizophrenia in a city of 2 million persons. The incidence rate of
schizophrenia in this population is 5/100,000 persons each year. What percent of the
1,000 cases were newly diagnosed in 2012?
10%
3. Which of the following is an advantage of active surveillance?
C-More accurate due to reduced reporting burden for health care providers
4. What would be the effect on age-specific incidence rates of uterine cancer if women with
hysterectomies were excluded from the denominator of the calculations, assuming that
there are some women in each age group who have had hysterectomies?
C- the rates would tend to increase
5. A survey was conducted among the nonhospitalized adult population of the United States during
2008 through 2011. The results from this survey are shown below.
- 18-29 years --- 4% - 30-39 years --- 10%
-40-49 years --- 22% - 50-59 years --- 43% -60-69 years --- 54% - 70 and older --- 64%
The researchers stated that there was an age related increase in the risk of hypertension in this
population. You conclude that the researchers' interpretation:
D- is incorrect because prevalence is used
6. The incidence rate of active cases of TB for the 6-month period was
B- 14 per 100,000 population
7. The prevalence rate of active TB as of June 30, 2012, was
C- 144 per 100,000 population
8. Disease X has duration of 15 years and a low incidence. Disease Y has a duration of 5 years
and a low incidence. Comparing disease X to Y in the same population, we would expect
Disease x to have a:
 C- higher prevalence
9. The following health statistics are available on the internet for country Z about two disease
outcomes. Disease A has an annual incidence of 225 per 100,000 population and an annual
mortality rate of 150 per 100,000. Disease B has an annual incidence of 500 per 100,000
population and the same annual mortality rate as disease A. Neither disease A or B has a
curve. What would you conclude regarding the burden of these diseases in country Z?
D- disease b has a higher prevalence than disease a
10. Chikungunya virus infection was recently introduced into the Dominican Republic. During the
first year after introduction, the virus has infected a total of 251,880 people in the
Dominican Republic, which has a population size of 10.4 million people. Infection by the
chikungunya virus is rarely fatal. Which of the following is correct?
D- the 1 year cumulative incidence of chikungunya is 24.2 per 1,000 persons

Chapter 4
1. In an Asian county with a population of 6 million people, 60,000 deaths occurred during the
year ending Dec 31, 2010. These included 30,000 deaths from cholera in 100,000 people
who were sick with cholera. What was the cause specific mortality rate from cholera in 2010?
5/1,000
2. What was the case fatality from cholera in 2010?
30%
3. Age adjusted death rates are used to
E - eliminate the effects of differences in the age distributions of populations in comparing
death rates
4. the mortality rate from disease X in city A is 75/100,000 in persons 65 to 69 years old. The
mortality rate from the same disease in city B is 150/100,000 in persons 65 to 69 years old .
The inference that disease X is two times more prevalent in persons 65 to 69 years old in
city B than it is in persons 65 to 69 years old in city A is:
B- incorrect because of failure to distinguish between prevalence and mortality
5. the incidence rate of a disease is five times greater in women than in men, but the prevalence
rates show no sex difference. The best explanation is that:
B- the case fatality from this disease is greater in women
6. For a disease such as pancreatic cancer, which is highly fatal and of short duration:
A- incidence rates and mortality rates will be similar
7. In 1990, there were 4,500 deaths due to lung disease in miners aged 20 to 64 years. The
expected number of deaths in this occupation group, based on age-specific death rates from
lung diseases in all males aged 20 to 64 years, was 1,800 during 1990. What was the
standardized mortality ratio (SMR) in lung diseases in miners (in %)?
2.5 or 250
 8.
9.
10. D-The rate of death from lung cancer and carpenter is from 1968 to 1967 was greater than would've
been expected for a group of men of similar ages and occupations

11.
9.6/1,000
12. E

Chapter 5
1. A physical examination was used to screen for breast cancer in 2,500 women with biopsy-proven
adenocarcinoma of the breast and in 5,000 age- and race-matched control women. The results of
the physical examination were positive (i.e., a mass was palpated) in 1,800 cases and in 800 control
women, all of whom showed no evidence of cancer at biopsy.The sensitivity of the physical
 examination was?
72.0% TP: 1800, TN: 4200 FP: 800 FN: 700
2. The specificity was?
84.0%
3. The positive predictive value was?
69.2%
4. A screening test is used in the same way in two similar populations, but the proportion of
false-positive results among those who test positive in population A is lower than that among those
who test positive in population B.
D- the prevalence of disease is higher in population A
5. A physical examination and an audiometric test were given to 500 persons with suspected hearing
problems, of whom 300 were actually found to have them. The results of the examinations were as

Compared with the physical examination, the audiometric test is:

D- more sensitive and less specific
6. Two pediatricians want to investigate new a laboratory test identify streptococcal infections.
Dr. Kidd uses a standard culture test which has a sensitivity of 90% in a specificity of 96%.
Dr. child uses the new test which is 96% sensitive and 96% specific. If 200 patients undergo
quadruple test which of the following is correct?
B-Dr. Kidd will correctly identify fewer people with streptococcal infection the doctor child
7. The hemoccult test has the sensitivity of 70% in a specificity of 75% if Nottingham has a
prevalence of 12 per 1000 for colon cancer, what is the positive predictive value of the test?
3.3%
8. If the Hemoccult test result is negative no further testing is done. If Hemoccult test result is positive,
the individual have a second stool sample test. If this second sample also test positive for blood
the individual will be referred for more extensive evaluation. What is the effect on net sensitivity and
net specificity of this method of screening?
B- Net sensitivity is decreased and net specificity is increased

Chapter 6

1.
What is the probability of surviving for 3 years?
54.8%
 2. An important assumption in this type of analysis is?
C- no change has occurred in the effectiveness of the treatment during the period of the study

3. Which of the following is a good index of the severity of a short-term, acute disease?
C- case fatality
4. A diagnostic test has been introduced that will detect a certain disease 1 year earlier than it is
usually detected. Which of the following is most likely to happen to the disease within the 10 years
after the test is introduced?
B- the apparent 5-year survival will increase
5. Which of the following statements about relative survival is true?
C- It is generally closer to observed survival in young populations

Chapter 7
1. A case control study is characterized by all of the following except:
C- incidence rates may be computed directly
2. Residents of three villages with three different types of water supply were asked to participate in the
survey to identify cholera carriers. Because several cholera deaths had occured recently virtually
everyone present at the time underwent examination. The proportion of residents in each village
who are carriers was computed in compared to what is the proper classification for the study?
A- cross sectional study
3. Which of the following is a case control study?
C- obtaining histories and other information from a group of known cases and from a comparison
group to determine the relative frequency of a characteristic or exposure under study
4. In a study begun in 1965, a group of 3,000 adults in Baltimore were asked about alcohol
consumption. The occurrence of cases of cancer between 1981 and 1995 was studied in
this group. This is an example of:
B- prospective cohort study
5. In a small pilot study, 12 women with endometrial cancer (cancer of the uterus) and 12 women
with no apparent disease were contacted and asked whether they had ever used estrogen.
Each woman with cancer was matched by age, race, weight, and parity to a woman without
disease. What kind of study design is this?
C- case control study
6. The physical examination records of the entire incoming freshman class of 1935 at the
University of Minnesota were examined in 1977 to see if their recorded height and weight
at the time of admission to the university was related to the development of coronary heart
disease by 1986. This is an example of:
D- a retrospective cohort study
7. In a case-control study, which of the following is true?
E-The proportion of cases with the exposure is compared with the proportion of controls with
the exposure, The investigator may choose to have multiple comparison groups., Recall
bias is a potential problem
8. In which one of the following types of study designs does a subject serve as his own control?
D- case crossover study
9. Ecologic fallacy refers to
C-Ascribing the characteristics of a group to every individual in that group
10. Researcher wants to investigate if tea consumption increases the risk of CHD. He uses a case control
study to answer the question. CHD is rare in younger people. Which two groups are best to enroll
and compare for this purpose?
C- The group of CHD cases and a group of those who do not develop CHD match for age
11. Which one of the following is a true conclusion concerning matching?
 C- matching on many variables may make it difficult to find an appropriate control

Chapter 8
1. In cohort studies of the role of a suspected factor in the etiology of a disease, it is essential that:
D-The exposed and nonexposed groups under study be as similar as possible with regard to
possible confounding factors
2. Which of the following is not an advantage of a prospective cohort study?
A- It usually costs less than a case-control study
3. Retrospective cohort studies are characterized by all of the following except:
C-The required sample size is smaller than that needed for a prospective cohort study
4. A major problem resulting from the lack of randomization in a cohort study is:
A-The possibility that a factor that led to the exposure, rather than the exposure itself,
might have caused the disease
5. In a cohort study, the advantage of starting by selecting a defined population for study before any of its m
C-. A number of exposures can be studied simultaneously
6. In 2010, investigators were interested in studying early-adult obesity as a risk factor for cancer mortality
The investigators obtained physician health reports on students who attended the University
of Glasgow between 1948 and 1968. These reports included records of the students' heights
and weights at the time they attended the university. The students were then followed through
2010. Mortality information was obtained using death certificates. This study can best be
described as a:
D- retrospective cohort study
7. The researcher used the stored blood samples to measure the serum level of CRP, a marker of
Systemic inflammation. The study initiated in 2010 is an example of a:
B- nested case control study

Chapter 10/11
1. The major purpose of random assignment in a clinical trial is to
E: Reduce selection bias in the allocation of treatment
2. An advertisement in a medical journal stated that “2,000 subjects with sore throats were
treated with our new medicine. Within 4 days, 94% were asymptomatic.” The
advertisement claims that the medicine was effective. Based on the evidence given
above, the claim:
E: May be incorrect because no control or comparison group was involved
3. The purpose of a double blind study or double masked study is to:
C:Avoid observer and subject bias
4. In many studies examining the association between estrogens and endometrial cancer
of the uterus, a one-sided significance test was used. The underlying assumption
justifying a one-sided rather than a two-sided test is:
B:Expectation before doing the study was that estrogens cause
endometrial cancer of the uterus
5. In a randomized trial, a planned crossover design:
B:Must take into account the problem of possible residual effects of the
first therapy
6. A randomized trial comparing the efficacy of two drugs showed a difference between the
two. Assume that in reality, however, the two drugs do not differ. This is therefore an
example of the following:
A: Type 1 error
 7. All of the following are potential benefits of a randomized clinical trial, except:
C:The external validity of the study is increased
8. A drug company maintains that a new drug G for a certain disease has a 50% cure rate
as compared with drug H which only has a 25% cure rate. You were asked to design a
clinical trial comparing drugs G and H. Using the preceding table, estimate the number of
patients needed in each therapy group to detect such a difference with 𝞪=0.05
two-sided, and 𝛃=0.20. The number of patients needed in each therapy group is.
57
i. Lower cure rate= 0.25 -> difference 0.50-0.25= 0.25
ii. Look at the table
9. Choose the best that you signed on the list below for each of the following research
questions. Each study design can only be used once.
a. B- Cross sectional study
b. C- Case control study
c. E-Randomized trial
d. D- Prospective cohort
e. A- Ecologic study
10. With intention to treat analysis, calculate the cumulative incidence ratio for recurrent
stroke using standard of care as a reference answer should be around into decimal
places.
a. Cumulative incidence ratio= 0.67
i. Group 1: patients with recurrent stroke= 30, total patients randomized to
drug a= 150, cumulative incidence= 30/150= 0.20
ii. Group 2: patients with recurrent stroke= 45, total patients randomized to
standard of care= 150, cumulative incidence= 45/150= 0.30
iii. 0.20/0.30= 0.67
11. What's the per protocol analysis, calculate the cumulative incidence ratio for recurrent
stroke using standard of care is the reference. Answers should be rounded to decimal
places.
a. Cumulative incidence ratio= 43
i. Patients who took drug A: Group 1=90, Group 2= 20, total patients= 110,
patients with recurrent stroke= 15, cumulative incidence= 15/110= 0.136
ii. Patients who took standard of care: Group 1=60, Group 2= 130, total
patients= 190, patients with recurrent stroke= 60, cumulative incidence=
60/190= 0.3158
iii. 0.136/0.3158= 0.43-> 43

Chapter 12
1. Of 2,872 persons who had received radiation treatment in childhood because of an enlarged thymus
cancer of the thyroid developed in 24 and a benign thyroid tumor developed in 52. A comparison group
consisted of 5,055 children who had received no such treatment (brothers and sisters of the children
who had received radiation treatment). During the follow-up period, none of the comparison group
developed thyroid cancer, but benign thyroid tumors developed in 6. Calculate the relative risk for
benign thyroid tumors.
15.3
 2. What is the estimated relative risk of cancer when analyzing this study as a matched-pairs?
D- 3.00
3. Unmatch the pairs. What is the estimated relative risk of cancer when analyzing this study
as an unmatched study design?
E- 4.00
4. In a study of a disease in which all cases that developed were ascertained, if the relative risk for the
association between a factor and the disease is equal to or less than 1.0, then:
E- there is either no association or a negative association

5.
4.5
6. 6.3
7. 1:7
8.

E- lowest in the Oldest age group

9. E- the initial examination measures the prevalence of ASHD, whereas…
 10.
1.94
11. 1.50
12. The odds of prostate cancer are 50% higher among never aspirin users compared to ever aspirin
users
13. Which of the following generally cannot be estimated in a case control study?
B- incidence rate

Chapter 13
1. Studies have found that approximately 85% of cases of lung cancer are due to cigarette smoking.
This measure is an example of
B- an attributable risk

2.
27.5/1,000
3. 84.6%
4. Cohort study of smoking in lung cancer the incidence of one cancer among smokers was found to be
9/1000 and the incidence among non smokers was 1/1000. From another source we know that
45% of the total population were smokers. The incidence of lung cancer attributable to smoking in
The total population is:
3.6/1,000
5. The proportion of the risk in the total population that is attributable to smoking is
 78.3%

Chapter 14
1. In a large case-control study of patients with pancreatic cancer, 17% of the patients were found to be
diabetic at the time of diagnosis, compared to 4% of a well-matched control group
(matched by age, sex, ethnic group, and several other characteristics) that was examined for diabetes
at the same time as the cases were diagnosed. It was concluded that the diabetes played a causal
role in the pancreatic cancer. This conclusion:
C-May be incorrect because of failure to establish the time sequence between onset of the
diabetes and diagnosis of pancreatic cancer
2. An investigator examined cases of fetal death in 27,000 pregnancies and classified mothers
according to whether they had experienced sexual intercourse within 1 month before delivery. It was
found that 11% of the mothers of fetuses that died and 2.5% of the mothers of fetuses that survived
had had sexual intercourse during the period. It was concluded that intercourse during the month
preceding delivery caused the fetal deaths. This conclusion:
A- May be incorrect because mothers who had intercourse during the month before childbirth may
differ in other important characteristics from those who did not
3. All of the following are important criteria when making causal inferences except:
E- predictive value
4. Factor X is:
B-A necessary, but not sufficient, cause
5. Factor A is:
D- neither necessary nor sufficient

Chapter 15
1. Which of the following is an approach to handling confounding?
E- all of the above
2. Which of the following approaches can handle confounding at the design stage of the study?
C- restriction
3. It has been suggested that physicians may examine women who use oral contraceptives more often
or more thoroughly than women who do not. If so, and if an association is observed between
phlebitis and oral contraceptive use, the association may be due to:
C- surveillance bias

4.
 12
5. 18.7
6. 9
7. 6.2
8. Based on the description given above, what source of bias is least likely to be present in this study?
D- bias due to loss of subjects from the control group over time
9. In 1990, a case-control study was conducted to investigate the positive association between artificial
sweetener use and bladder cancer. Controls were selected from a hospital sample of patients
diagnosed with obesity-related conditions. Obesity-related conditions have been positively associated
with artificial sweetener use. How would the use of these patients as controls affect the estimate of
the association between artificial sweetener use and bladder cancer?
B- the estimate of association would tend to underestimate the true association

Sample Final Exam

Multiple Choice

Epidemiology Final Exam - Morales

1. The following are differences between randomized clinical trials and cohort studies, except:

● Investigation of etiologic agent

● Comparison of exposed with nonexposed individuals
● Randomization
● Uncertainty as to whether the association of exposure with disease is due to other
factors
● None of the above

2. If a positive association exists between the exposure and the disease, we would expect that
the

● proportion of the exposed group (diseased) would be less than the proportion of the
nonexposed group (diseased).
 ● proportion of the exposed group (diseased) would be equal to the proportion of the
nonexposed group (diseased).
● Proportion of the exposed group (diseased) would be greater than the proportion
of the nonexposed group (diseased).
● both a and c
● None of the above

3. In a cohort study, which measure of association can be calculated?

● prevalenceratio
● relative risk
● odds ratio
● both b and c
● None of the above

4. In a case-control study, which measure of association can be calculated?

● prevalenceratio
● relative risk
● odds ratio
● both b and c
● None of the above

5. In a cross-sectional study, which measure of association can be calculated?

● prevalence ratio
● relative risk
● odds ratio
● both b and c
● None of the above

6. In a case-control study, which of the following is false?

● The proportion of cases with the exposure is compared with the proportion of controls
with the exposure
● Disease rates are compared for people with the factor of interest and for people
without the factor of interest
● The investigator may choose to have multiple comparison groups
● Recall bias is a potential problem
● None of the above

7. In cohort studies of the role of a suspected factor in the etiology of a disease, it is essential
that:

● The exposed and nonexposed groups under study be as similar as possible with
regard to possible confounding factors
● There be equal numbers of persons in both study groups
● At the beginning of the study, those with the equal risks of having the factor
● The study group with the factor and the study group without the factor be representative
of the general population
● None of the above
8. All of the following are potential biases in a cohort study, except:

● Assessment of outcome
● Information
● Recall
● Nonresponse and attrition
● Analytic

Page 1

Epidemiology Final Exam - Morales

9. Which of the following is not an advantage of a prospective cohort study?

● Precise measurement of exposure is possible

● Many disease outcomes can be studied simultaneously
● Incidence rates can be calculated
● It usually costs more than a case-control study
● None of the above
10. Retrospective cohort studies are characterized by all of the following except:
● The required sample size is smaller than that needed for a prospective cohort study
● The required sample size is similar to that needed for a prospective cohort study
● The study groups are exposed and non-exposed
● Incidence rates may be computed
● They are useful for rare exposures
11. A major problem resulting from the lack of randomization in a cohort study is:
● The possibility that a greater proportion of people in the study may have been exposed
● The possibility that a smaller proportion of people in the study may have been exposed
● That, without randomization, the study may take longer to carry out
● The possibility that factors that lead to the exposure, rather than the exposure
itself, might have caused the disease
● Planned crossover is more likely
12. In a cohort study, the advantage of starting by selecting a defined population for
study before any of its members become
exposed, rather than starting by selecting exposed and nonexposed individuals, is that:
● A number of outcomes can be studied simultaneously
● The study can be completed more rapidly
● A number of exposures can be studied simultaneously
● The study will cost less to carry out
● None of the above
13. A case-control study is characterized by all of the following except:
● It is relatively inexpensive compared with most other epidemiologic study designs
● Patients with the disease are compared with persons without the disease
● Incidence rates may be computed directly
● Assessment of past exposure may be biased
● Definition of cases may be difficult
14. Which of the following is a case-control study?
● Study of past mortality or morbidity trends to permit estimates of the occurrence of
disease in the future
 ● Analysis of previous research in different places and under different circumstances to
permit the establishment of hypothesis
based on cumulative knowledge of all known factors
● Obtaining histories and other information from a group of known cases and from a
comparison group to determine the relative frequency of a characteristic of
exposure under study
● Study of the incidence of cancer in men who have quit smoking
● Both a and c
15. In a study begun in 1965, a group of 3,000 adults in Baltimore were asked about
alcohol consumption and followed until the
onset of cancer. The occurrence of cancer between 1981 and 1995 was studied in this
group. This is an example of:
● A cross-sectional study
● A concurrent cohort study
● A retrospective cohort study
● A clinical trial
● A case-control study

Page 2

Epidemiology Final Exam - Morales

16. Residents of four villages with four different types of water supply were asked to participate
in a survey to identify cholera carriers. Because several cholera deaths had occurred recently,
virtually everyone present at the time underwent examination. The exposure to the water supply
and disease status was assessed simultaneously. The proportion of residents in each village
who were carriers was computed and compared. What is the proper classification for this study?

● A case-control study
● A concurrent cohort study
● A retrospective cohort study
● A cross-sectional study
● An experimental study
17. The physical examination records of the entire incoming freshman class of 1935 at
the University of Minnesota were examined in 1977 to see if their recorded height and
weight at the time of admission to the university was related to the development of
coronary heart disease by 1986. This is an example of:
● A retrospective cohort study
● A cross-sectional study
● A case-control study
● A concurrent cohort study
● An experimental study
18. In a small pilot study, 12 women with endometrial cancer and 12 women with no
apparent disease were contacted and asked whether they had ever used estrogen. Each
woman with cancer was matched by age, race, weight, and parity to a woman without
disease. What kind of study design is this?
● A concurrent cohort study
● A retrospective cohort study
● A cross-sectional study
● A case-control study
 ● An experimental study
19. In a large case-control study of patients with pancreatic cancer, 17% of the patients
were found to be diabetic at the time of diagnosis, compared to 4% of a well-matched
control group (matched by age, sex, ethnic group, and several other characteristics) that
was examined for diabetes at the same time as the cases were diagnosed. It was
concluded that the diabetes played a causal role in the pancreatic cancer. This
conclusion:
● May be incorrect because there is not control group
● May be incorrect because of failure to establish the time sequence between onset
of the diabetes and diagnosis of pancreatic cancer
● May be incorrect because of less complete ascertainment of diabetes in the pancreatic
cancer cases
● May be incorrect because of more complete ascertainment of pancreatic cancer in
nondiabetic persons.
● Is correct
20. Ecologic fallacy refers to:
● Assessing exposure in large groups rather than in many small groups
● Assessing outcome in large groups rather than in many small groups
● Ascribing the characteristics of a group to every individual in that group
● Examining correlations of exposure and outcomes rather than time trends
● Failure to examine temporal relationships between exposures and outcomes
Factor A, B, or C can each individually cause a certain disease without the other two
factors, but only when followed by exposure to factor X. Exposure to factor X alone is not
followed by the disease, but the disease never occurs in the absence of exposure to
factor X.
21. Factor X is:
● A necessary and sufficient cause
● A necessary, but not sufficient, cause
● A sufficient, but not necessary, cause
● None of the above
● All of the above

Page 3

22. Factor A is:

● A necessary and sufficient cause

● A necessary, but not sufficient, cause
● A sufficient, but not necessary, cause
● None of the above

Epidemiology Final Exam - Morales

23. An investigator examined cases of fetal death in 27,000 pregnancies and classified mothers
according to whether they had experienced sexual intercourse within 1 month before delivery. It
was found that 11% of the mothers of fetuses that died and 2.5% of the mothers of fetuses that
survived had had sexual intercourse during the period. It was concluded that intercourse during
the month preceding delivery caused the fetal deaths. This conclusion:

● May be incorrect because mothers who had intercourse during the month before
childbirth may differ in other important characteristics from those who did not
 ● May be incorrect because there is no comparison group
● May be incorrect because prevalence rates are used where incidence rates are needed
● May be incorrect because of failure to achieve a high level of statistical significance
● Both a and b
24. Which of the following is an approach to handling confounding?
● individual matching
● stratification
● groupmatching
● adjustment
● all of the above
25. In a study of a disease in which all cases that developed were ascertained, if
the relative risk of the association between a
factor and the disease is equal to 1.0, then:

a. There is no association between the factor and the disease

b. The factor protects against development of the disease

c. There is a positive association between the factor and the disease
d. The comparison group used was unsuitable, and a valid comparison is not possible
e. There is either no association or a negative association between the factor and the disease

26. Several studies have found that approximately 85% of cases of lung cancer are due to
cigarette smoking. This measure is an

example of:

● An incidence rate
● An attributable risk
● A relative risk
● A prevalence risk
● Aproportionatemortalityratio
27. When a study outcome is rare in all strata used for an analysis, the: a. odds
ratio estimate of causal effects will not approximate the risk ratio
b. odds ratio estimate of causal effects will approximate the risk ratio
c. the odds ratio will be further from 1 than the risk ratio
d. both a and c
e. none of the above
28. In a case-control study cases can be selected from:
● Hospitals
● Registries
● Physician’s practice patients

d.All of the above

e. None of the above

29. The following are some approaches in selection of controls, except:

Page 4
a. Neighborhood approach b.door-to-door approach
c. high prevalence approach d.best friend approach
e. hospitalized patients approach

30. The Doll and Hill study of Carcinoma of the Lung, was an example of a: a. Randomized
Clinical Trial
b.Ecological Study
c. Cross-Sectional Study

d.Case-Control Study

e. None of the above

Questions 31-33: Identify the study design in the figures below using the following:

a. Prospective Cohort

31.

32. a

33. b

b. Retrospective Cohort

c. Case Control

Epidemiology Final Exam - Morales

Questions 34-38. In conducting human studies, there is a particular sequence that is followed.
Number to order correctly.

a=1; b=2; c=3; d=4; e=5

34. __c___ Case-control studies

35. __a___ Clinical Observation
36. __e___ Randomized Trials
37. __b___ Available Data
38. __d___ Cohort studies
True or False

39. __b_____ Only case-control, not cohort, studies are designed to determine whether there is
an association between exposure to factor and the development of a disease.

40. __b_____ Relative risk can be calculated for both case-control and cohort studies.
41. __b_____ Longitudinal and prospective studies are both, types of case-control studies.
42. _______ It is possible to conduct a study that is a combination of prospective and
retrospective cohort studies.
Page 5

Epidemiology Final Exam - Morales

43. __b_____ A Cross-sectional study is used in investigating the etiology of disease.

44. __b_____ Matched odds ratio are based on the concordant pairs in cohort studies.
45. __b_____ The Framingham study is a classic cross-sectional study and contributed to
the study of carcinogens.
46. __b_____ The prevalence calculated from a case-control study does reflect the true
prevalence of disease in a population.
47. __a_____ In a cohort study, you can select a defined population before exposure occurs
or is identified.
48. __a_____ Background risk refers to the prevalence of disease in the nonexposed group
of people.
49. __b_____ The odds ratio result of 4 indicates a negative relationship between exposure
and disease.
50. __a_____ In a case-control study, the cases of disease that are identified are prevalent
cases of the disease in question.
51. __a_____ Randomized clinical trials are considered the “gold standard” of study
designs.
52. __b_____ A cross-sectional study begins by selecting cases without disease and
controls with disease.
53. __b_____ Attributable risk expresses the very least that we can hope to accomplish in
reducing the risk of the disease if we

completely eliminate the exposure.

54. __a_____ The hallmark of the case-control study is that it begins with people with disease
and compares them to people without the disease.

55. __b_____ Case-crossover studies assess exposure and disease outcome at the same
time.
56. __b_____ Absolute risk does not indicate whether the exposure is associated with an
increased risk of disease
57. __a_____An odds ratio can approximate the relative risk when the disease is rare.
58. __a_____ Concordant pairs are ignored in calculating matched odds ratios because they
do not contribute to our knowledge

of how cases and controls differ in regard to past history of exposure.

59. __b_____ Studies of group characteristics to determine if there is an association

between an exposure and the risk of disease
60. __b_____ Prospective cohort studies minimize the potential for recall and other bias in
assessing the exposure and have

greater validity of the exposure assessments.

61. __b_____ Temporal relationship between exposure and disease is easy to establish in
cross-sectional studies.
62. __a_____ If a case control yields evidence that a certain exposure is suspect, we might
do a cohort study.
 63. __a_____ If an association is real, disease morbidity will decrease by removing the
exposure.

Calculation

64. Calculate the relative risk.

● 0.27
● 3.74
● 0.20
● 2.11
● None of the above

Asbestos Exposure Not Exposed to Asbestos

Cancer

100 50

No Cancer

4,900 6,550

Page 6

65. Calculate the odds ratio.

● 0.27
● 3.74
● 0.20
● 2.11
● None of the above
66. Calculate the attributable risk.

Cases Exposure 100

Not Exposed 50

Control

4,900 6,550

Epidemiology Final Exam - Morales

CHD CHD Does Not Attributable Risk (AR) in Exposed

Develops Develop Group
Smoke 300 4700 Doesn’t Smoke 50 4850

● 0.05
● 0.06
● 1.93
● 0.01
● None of the above

Questions 67-68. The table below illustrates the interaction of factors to cause disease. Fill in
the missing cell if the model is:

Incidence Rates

Factor -

67. Additive a. 20.0

Factor A -+

2.0 8.0 + 18.0

b. 26.0
c. 10.0
d.24.0
e. None of the above

68. Multiplicative

● 72.0
● 64.0
● 26.0
● 32.0
● None of the above

69. Calculate the matched-pairs odds ratio:

Cases Exposed Not Exposed

Controls
Exposed Not Exposed 25 20

55

● 1.25
● 4.0
● 5.0
● 1.0
● None of the above

Page 7

Epidemiology
Final Exam - Morales
Questions 70-71: In an Asian country with a population of 6 million people, 60,000 deaths occurred during the
year. These included 30,000

deaths from cholera in 100,000 people who were sick with cholera.

70. What is the cause-specific mortality rate?

● 5 per 1,000
● 50 per 1,000
● 500 per 1,000
● 30 per 1,000
● 300 per 1,000
71. What is the case-fatality rate from cholera?
● 0.5%
● 5%
● 0.3%
● 3%
● 30%
72. Calculate the attack rates for Food X for those who Ate the food and those that did not eat the food:
● 15%; 27%
● 85%; 27%
● 73%; 15%
● 15%; 73%
● 85%; 73%

Questions 73-74: Five new cases of HIV/AIDS were reported. This brings the total number of active HIV/AIDS cases
this year (2006) to 56; total population is 100,000.

73. What is the prevalence rate of HIV/AIDS?

● 5 per 100,000
● 5 per 20,000
● 56 per 100,000
● 56 per 20,000
● 20,000 per 100,000
74. WhatistheincidencerateofHIV/AIDS?
● 5 per 100,000
● 5 per 20,000
 ● 56 per 100,000
● 56 per 20,000
● 20,000 per 100,000
75. A Prevalence survey identified 1,500 cases of schizophrenia in a city of 2 million persons. The incident rate
of schizophrenia in this population is 15 per 100,000 persons each year. What percent of the 1,500 cases
were newly diagnosed?
● 10%
● 13%
● 18%
● 20%
● 25%

Ate the Tuna Did not eat Tuna

Ill Well Total Attack Rate Ill Well Total Attack Rate

17 3 20 ? 11 4 15 ?

Page 8