Measuring and Interpreting Morbidity and Mortality I Answer Key

September 2019

et al.

METHODS
Surveillance Methodology and Definitions
The Active Bacterial Core surveillance system (ABCs) is an ongoing, population-based, active laboratory surveillance
system and is a component of the Emerging Infections Program (EIP) of the US Centers for Disease Control and
Prevention (CDC). From July 2004 through December 2005, 9 EIP sites conducted surveillance for invasive MRSA
infections.

Question 1:
A. In the methods section above, the authors of the article describe the surveillance activities as “active”
surveillance. What characteristics of the surveillance program made it “active”?

The CDC utilized a program to go into these hospitals (either in person or electronically) to collect
the surveillance data.

B. In what way would the system differ if it had been a “passive” surveillance system?

A passive surveillance system would ask the hospitals and the community to submit this
information.

C. Do you think that the incidence estimates that result from a “passive” system would differ from those of an
“active” system? If yes, how and why?

The incidence rates for the passive surveillance would likely be smaller than for those generated as a
result of active surveillance. The incidence rates under a passive system might also be less accurate
reporting, since the CDC investigates each case in this active system.

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Statistical Analysis
“We selected cases reported from July 2004 through December 2005 to describe epidemiologic, clinical, and
microbiological characteristics. We included only cases reported from January through December 2005 for the
annual 2005 incidence rate calculations. Recurrent cases were excluded from incidence calculations. We used
US Census Bureau bridged-race vintage postcensus population estimates for 2005, provided by the National
Center for Health Statistics for surveillance area and national denominator values.”

Question 2. The excerpt from the statistical section above describes the sources of information that were
used to generate the incidence rates. The authors generated which type of incidence: Cumulative
incidence or Incidence Density?

These are Cumulative Incidence measures, since the authors use census data for the denominator
and NOT person-years.
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“The 2006 NHIS adult core questionnaire, containing questions on cigarette smoking and cessation attempts,
was administered by in-person interview to a nationally representative sample of 24,275 persons in the
noninstitutionalized U.S. civilian population aged >18 years; the overall response rate was 70.8%. To classify
smoking status, respondents were asked, “Have you smoked at least 100 cigarettes in your entire life?”; Those
who answered “yes” were asked, “Do you now smoke cigarettes every day, some days, or not at all?””(Source:
Cigarette Smoking Among Adults --- United States, 2006, MMWR, Morb Mortal Wkly Rep 2007;56 No. 44.

The results of the NHIS from 1965 through 2015 are presented below (1965-2006 on the left and 2005-2015 on
the right). The source for the more recent data is Jamal A, King BA, Neff LJ, Whitmill J, Babb SD, Graffunder
CM. Current Cigarette Smoking Among Adults — United States, 2005–2015. MMWR Morb Mortal Wkly Rep
2016;65:1205–1211. DOI: http://dx.doi.org/10.15585/mmwr.mm6544a2.

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 FIGURE 1. Percentage of adults who were
current cigarette smokers,* overall and by sex —
National Health Interview Survey, United States,
2005–2015

* Persons who reported smoking ≥100 cigarettes

during their lifetime and who, at the time of
interview, reported smoking every day or some days .

Question 3: Which type of epidemiologic measures are presented in the above figures? Prevalence or
Incidence?

These percentages are prevalence measures.

The 2016 publication states “NHIS is an annual, nationally representative, in-person survey of the
noninstitutionalized U.S. civilian population. The NHIS sample adult core questionnaire is administered to a
randomly selected (sample) adult in the household, and, in 2015, included 33,672 adults aged ≥18 years; the
response rate was 55.2%.”

Question 4: What is meant by an overall response rate? Why do the authors report it? What could
account for the change in response rate to the NHIS? Why is this important?

The response rate is calculated as the number responding divided by the surveyed x 100. 75%
or above is considered to be a good response rate. With a low response rate, bias could be
introduced into the measurement. Non-response bias can occur when respondents different in
some way from respondents. A low response rate and non-response bias can jeopardize the
generalizability of the results from the study.

Question 5: What do the two figures on the prior page tell you about smoking trends in the US since
1965? Between 2003 and 2006? After 2006?

The percentage of adults who smoke in the US has been declining since 1965. A greater
proportion of men smoke than women. Since 2003 the decline appears to be leveling off and then
began to decline again 2010.

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Question 6: What does the figure below tell you about smoking patterns?

FIGURE 2. Current cigarette smoking* among adults by degree of psychological distress† and age group§ —
National Health Interview Survey, United States, 2015

* Persons who reported smoking ≥100 cigarettes during their lifetime and who, at the time of interview, reported smoking every day or some days.

†
Degree of psychological distress is based on Kessler psychological distress scale (K6), the four-category measure: no psychological distress (score = 0),
low psychological distress (score = 1–5), moderate psychological distress (score = 6–10), and high psychological distress (score = 11–24). Error bars
represent the 95% confidence interval for each estimate.

§
A significant trend across Kessler scale psychological distress groups (p<0.05) was found overall and for each age groups.

Disparities in cigarette smoking prevalence exist by age and degree of psychological stress
reported by respondents. For example, in 2015, cigarette smoking prevalence was higher among
persons who have serious psychological distress (40.6%) than among persons without serious
psychological distress (14.0%). Comparisons between subgroups can be made by looking at the
95% confidence intervals (error bars).