ee » = 2006 EPIDEMIOLOGY EXAMINATION ANSWERS —_— eee OGY EXAMINATION ANSWERS Question 4: a) ge- group | Males expected Females expected | Total f ona deaths deaths | ‘| 0a en eter a 113.18 240.20 | SSiostmey af 703.76 Bi54 175.30 15 to <30 915.65 523.36 7439.01 | 30 to = 45 1204.55 325.17 1529.72 Oto<45 2340.98 1043.25 3364.23 | SMR: Calculated based on (observediexpected) 450/3384 = 0.133 (13.3%) (5 marks) (©) Less than expected. This difference could be due to * underreporting of the TB deaths in Blantyre (2 marks) * differences in the population distribution of the Blantyre population compared to the standard (national) population used (2 marks) * actual differences due to better management of TB cases in Blantyre or better Socio-economic status of Blantyre (which reduces the TB case fatality rates) (2 marks) {c) To ensure that any differences in age and sex distribution between Blantyre and Malawi do not account for the differences in the TB mortality ie to control (adjust) for the confounding effects of age and sex on TB mortality (4 marks) Question 2 (@) To ensure that controls are representative of the population from where the Cases arose (health Center controls may not be representative of the controls ftom where the cases arose] (1 mark). Overall, this was an attempt to prevent selection bias (2 marks). {b) Student needs to show a table capturing the following figures and calculations Malaria Health Center ‘Community a Cases Controls Controls | Used mosquito coils st [90 69 | | Did not use mosquito coils _| 195 [150 1 SS ee* Odds ratio using health center controls=51"150/195*90=0.44, Odds ratio using community controls=51"164/195"69=0.62 (©) Any of the following statement are permissible * Malaria cases were §6% less likely to use mosquito coils than health center controls. Also, malaria cases were 38% less likely to use mosquito coils than community controls. (ideal answer: 3 marks) * The use of mosquito coils was 56% lower in malaria cases than in health center controls. The use mosquito coils was 38% lower in malaria cases than in community controls, (3 marks) * The odds (likelihood) of using mosquito coils were 56% lower in malaria cases than in health center controls. The odds (likelihood) of using mosquito coils were 38% lower in cases than controls. (3 marks) Less preferred options * When health center controls were used for comparison, the odds of having malaria was 56% lower among those who used mosquito coils than those who did not. When community controls were used for comparison, the odds of having malaria was 38% lower among those who usec! mosquito coils than those who did not. (2 marks) + Cases were 0.44 times as likely to use mosquito coils when compared with health center controls. Cases were 0.62 times as likely to use ‘mosquito coils when compared with community controls. (2 marks) * When health center controls were used for comparison, those who used ‘mosquito coils were 0.44 times as likely to be cases compared with those Who did not. When community controls were used for comparison, , those Who used mosquito coils were 0.62 times as likely be cases compared with those who did not. (2 marks) Any other statements (1 or 0 marks) (d) Sources of measurement bias * recall—mothers of children with malaria may remember better the use of mosquito coils than mothers of controls. In fact, in an attempt to show that the illness of the child is not their fault, they may overstate the use of mosquito coils. (1 mark) * interviewer bies—the interviewer may probe mothers of malaria cases about their use of mosquito coils more than the controls. (1 mark) (©) Possible confounders (students should identify those factors that are unequally distributed between cases and controls, using the p-values. Students who do not refer to the p-value lose 2 marks) + slept in rural area * kept antimalaria drugs * use of ITNs * poor knowledge of malaria (3 marks) (6) Control for confounders * stratified analysis—stratifying for factors mentioned in part (e) above. (2 marks)* _[oalstc regression analysis (mathematical modeling)—adjusting f factors mentioned in part (e) above, (2 marks) Please note that the question asks “based on the data provided in the table.“ (9) Student should mention the following {‘Gentity several communities (vilages, townships or TAs). (4 mark) * make or get a placebo (which looks like the “active” mosquito cal). (4 mark) * randomly allocate the placebo and “active” mosquito coils to different communities. (1 mark) * follow up under-five children to identify those presenting with malaria a mark) * Compare the incidence of malaria in placebo versus “active” mosquito coil communities. (1 mark) Question 3 (a) Study designs * Cross-sectional \\ identity a target population of women in the community or health facility (1 mark) ii, depending on the required sample size, use the total population of women or select a sample that is representation of the total Population of women (1 mark) ill ask the women about the use of oral contraceptives and examine them for the presence of breast cancer (1 mark) * Case-Control i. enroll breast cancer cases from cancer registry or enroll breast cancer cases as they are being diagnosed or already diagnosed at a health facility (7 mark) |. enroll appropriate controls for the breast cancer cases (1 mark) iil, ask the cases and controls about the use of oral contraceptives (1 mark) * Prospective cohort enroll breast cancer-free women who are using oral contraceptives (7 mark) ii, enroll breast cancer-free women not using oral contraceptives (1 mark) iii, follow them up over years to diagnose those who develop breast cancer in the two groups (1 mark) b) Study of choice * Case control study. Breast cancer is a rare condi consid appropriate because for such a rare condition one has to interview and Screen for cancer 10,000 women to get 1 breast cancer patient. (4 marks) (©) Limitations