MD3150E Epidemiology Biostatistics and Public Health Version 2

Closed questions – 0.4 point, Total: 20 points; True / False – 0.25 point, Total: 10 points;
Filling Gaps – 1 point, Total: 10 points. Total score – 40 points.

1. Mold and cockroaches are believed to be related to the development of asthma. Which of the
following determinants of health best describes this situation?
A: Behavior
B: Geography
C: Genetics
D: Environment
E: Socio-economic

2. Define incubation period

A The doubling time of the agent and the communicability time between exposures
B When someone is infected but does not show any symptoms
C Resistance of the entire community because of the people immunity within the
community
D Time from when the agent first invaded and the first symptom
E None of the above

3. Active immunity is
A Immunity gained from a person to person transaction
B The development of immunity from previous exposure to an agent before a vaccine or
natural infection
C Resistance of the entire community because of the people immunity within the
community
D Immunity gained from a person to person transaction
E None of the above

4. A specific case definition is one that:

A Is likely to include only (or mostly) true cases
B Is considered "loose" or "broad"
C Will include more cases than a sensitive case definition
D May include mild cases

5. What is the primary difference between risk and prevalence?

A Prevalence describes the number of diseased persons present in the population divided by the
number of persons in the population in a specified time period, whereas risk describes the
number of newly diseased person present in the population divided by the number of at-risk
persons in the population in a specified time period.
B Prevalence describes the number of diseased person present in the population in a specified
time period whereas risk describes the number of people who die from the disease in the
population in a specified time period.
C Risk describes the number of diseased persons present in the population divided by the
number of persons in the population during a specified time period, whereas prevalence
 describes the number of newly diseased person present in the population in a specified time
period divided by the number of at- risk persons in the population.

6. Which of the following best describes the retrospective design where subjects are sampled by
disease status and is often used when the investigator is interested in rare diseases?
a) intervention trial
b) case control study
c) retrospective cohort
d) ecologic study
e) none of the above

7. Which of the following studies is best described in this statement: “A study where the participants
receive one drug for heart disease and then later receive a different drug for heart disease."
a) randomized controlled trial
b) cohort study
c) cross-over clinical trial
d) intervention study
e) case-control study

8. Which of the following study designs is sometimes referred to as a “snapshot in time”?

a. Case-control study
b. Time to treat study
c. Cohort study
d. Cross-sectional study
e. Intervention study

9. Which of the following conclusions to explain the hypothetical statement that “Air pollution is
higher in New York City than in Washington D.C., but mortality from lung disease is lower in New
York City than in Washington D.C.” would be an example of ecologic fallacy?
a. Persons dying of lung disease in Washington D.C. may have moved from high air
pollution cities
b. Air pollution protects against lung disease deaths
c. People in New York City may have better health insurance than people in Washington
D.C.
d. New York City may provide better treatment for lung disease than Washington D.C.

10. When analyzing surveillance data by age, which of the following age groups is preferred? (Choose
one best answer)
a. 1-year age groups
b. 5-year age groups
c. 10-year age groups
d. Depends on the disease

11. A key feature of a cross-sectional study is that:

a. It usually provides information on prevalence rather than incidence
b. It is limited to health exposures and behaviors rather than health outcomes
c. It is more useful for analytic than descriptive epidemiology
d. It is used to commonly used to ascertain temporality
12. The epidemiologic triad of disease causation refers to:
a. Agent, host, environment
b. Time, place, person
c. Source, mode of transmission, susceptible host
d. John Snow, Robert Koch, Kenneth Rothman

13. Which term best describes the pattern of occurrence for a disease in a single area with usually no
more than 2–4 cases per week, if last week 13 case was reported?
a. Endemic
b. Outbreak
c. Pandemic
d. Sporadic

14. Age-related maculopathy is a leading cause of blindness among people 65 and older in the United
States, and is estimated to affect between 16 and 26% of people in this age group. In a recent
study by Klein, residents aged 43 to 86 years in the town of Beaver Dam, Wisconsin were asked to
participate in a study to determine whether cigarette smoking was related to age-related
maculopathy. At a baseline examination, participants were asked to report their lifetime smoking
habits. After 5 years, participants had an examination to determine whether they had developed
age-related maculopathy. Which of the following best describes the research design used by in
this study?
a. Population based cross-sectional study
b. Case cohort study
c. Nested case control study
d. Prospective cohort study
e. None of the above

15. Suppose a company wants to evaluate whether a new medical device works better than current
devices. It conducts a small experiment to assess the effectiveness of the new device. To conduct
the experiment, the company randomly assigns one group to the new medical device, which
requires users to stay well hydrated, and the other group to the old device. How should we
control for confounding variables?
A The group receiving the new device should simply receive the device without being asked
to stay hydrated.
B The group receiving the old device should also be required to stay hydrated.
C Participants should be able to choose which device is right for them.
D Experiment cannot be conducted as new and old devices require different conditions

16. All of the following are important criteria when making causal inferences except:
A Consistency with existing knowledge
B Dose-response relationship
C Consistency of association in several studies
D Strength of association
E Predictive value

17. Confounding can be controlled by

 A Stratifying by levels of the confounder
B Using direct and indirect adjustment
C Using multivariate regression analyses
D All of the above
E None of the above

18. _______ is the cause or set of causes of a disease and/ or condition

A. Education
B. Epidemiology
C. Etiology
D. Viruses

19. Which of the following best describes the similarities and differences in the three distributions
shown in Figure 1?

Figure 1.

a. Same mean, median, mode; different standard deviation

b. Same mean, median, mode; same standard deviation
c. Different mean, median, mode; different standard deviation
d. Different mean, median, mode; same standard deviation

20. If our sample value is close to the null/population value, we conclude that
a. Something happened in the study, but the effect is very small.
b. Something happened in the study; there is a significant effect.
c. We can neither accept nor reject the null.
d. Nothing happened in the study; there is no effect.

21. Interpret the meaning of one study’s reported rate ratio of 0.5 (95% CI 0.2, 0.9) for the association
between high level of Vitamin D consumption and breast cancer incidence.
a. There is no association between high Vitamin D consumption and breast cancer rates.
b. Those who consume a high level of Vitamin D are less likely than those who consume
little or Vitamin D, to have a high rate of breast cancer incidence, but it is not statistically
significant.
c. High Vitamin D consumption is associated with an increased breast cancer rate.
d. Those who consume a high level of Vitamin D are statistically significantly less likely than
those who consume low or no Vitamin D, to have a high rate of breast cancer incidence.

22. A Type II error occurs when

a. We incorrectly fail to reject a false null hypothesis.
b. We correctly reject a false null hypothesis.
c. We correctly fail to reject a false null hypothesis.
d. We incorrectly reject a true null hypothesis.
23. Which of the following is not one of the steps for hypothesis testing?
a. Deciding whether to reject or fail to reject the null hypothesis.
b. Choosing a cutoff value from your population to determine how close your sample is
to the population value.
c. Drawing a conclusion based on the results of your test.
d. Calculating the test statistic with the summary sample statistics.

24. Which factors tend to make a confidence interval wider?

a. Larger Sample
b. A Smaller Sample, Higher Variability and a Higher Confidence Level all contribute to
making an interval wider.
c. Higher Variability and Small Sample
d. Higher Variability
e. Small Sample and Confidence Level

25. The measure of whether the results of research were due to chance.
a. Mean
b. Median
c. Mode
d. p-value
e. r-value
f. Significance
g. Correlation

26. In a survey of representative sample of particular city It took people in our sample an average time
of 21 minutes to get to work one –way (95% CI 18.3-23.7)
A 95% of the 45 workers take between 18.3 and 23.7 minutes to get to work.
B There is a 95% chance that the mean time it takes all workers in this city to get to work is
between 18.3 and 23.7 minutes
C We are 95% confident that the mean time it takes all workers in this city to get to work is
between 18.3 and 23.7 minutes
D 95% of workers take between 18.3 and 23.7 minutes to get to work.
E None of the above

27. Interpret the meaning of one study’s reported odds ratio of 1.6 (95% CI 1.1, 3.4) for the
association between high level of fish oil consumption and prostate cancer.
a. Fish oil is protective against prostate cancer.
b. There is no association between fish oil intake and prostate cancer.
c. Cases are more likely than controls to have a high level of consumption of fish oil, but
it is not statistically significant.
d. Cases are statistically significantly more likely than controls to have a high level of
consumption of fish oil.

28. The way in which significance is reported statistically?

a. Mean
b. Median
c. Mode
d. p-value
e. r-value
f. Significance
 29. If the P value is below your alpha threshold (typically .05), what should you do?
A Accept the Alternative Hypothesis as true
B Reject the Null Hypothesis
C Accept the Null hypothesis as true
D Do different statistical test

30. When constructing a question in the PICO format, what does the letter O stand for?
a. Opportunity
b. Option
c. Order
d. Outcome
e. Outline

31. What study type(s) provide the best evidence for answering questions relating to prognosis or
risk?
a. Case-control or cohort studies
b. Case series or textbooks
c. Cross-sectional or case-control studies
d. Randomised controlled trials
e. Surveys or case reports

32. Which from the following statements are adequate a PICO question:
a. Is hydrotherapy better option for patients with osteoarthritis of the knee?
b. In patients with osteoarthritis of the knee is hydrotherapy more effective than
traditional physiotherapy in relieving the pain?
c. In patients with osteoarthritis is hydrotherapy effective in relieving the pain?
d. [Which therapy] provides the [best outcome] for patients with osteoarthritis?

33. How should you approach a clinical question with multiple possible interventions or outcomes?
a. Construct a series of PICOs, each containing one comparator and one outcome, until
all questions are answered.
b. Expand the PICO to contain all of the relevant comparators and outcomes
c. Expand the PICO to contain some, but not all of the extra comparators and outcomes
d. Ignore the other comparators and outcomes; one is enough to get the best evidence
e. It is not possible to use the PICO format for questions with multiple comparators or
outcomes.
For questions 34-42, please indicate the appropriate level for each prevention activities:
A. Primary
B. Secondary
C. Tertiary
D. Neither of them
34. ____ the addition of fluoride to water and toothpaste
35. ____ the use of a seat belt to prevent accident injuries
36. ____folic acid supplementation in pregnancy.
37. ____Testing cholesterol
38. ____Annual flu vaccinations
39. ____ Pap smears
40. ____ Testing cholesterol
41. ____ Prompt administration of thrombolytic therapy following Myocardial Infarction
42. ____Speech therapy following Cerebro-vascular accident
For each of the following, identify the appropriate letter from the time line in Figure 1 representing the
natural history of disease
43. ____ Onset of symptoms
44. ____ Usual time of diagnosis
45. ____ Exposure

Figure 2. Natural History of disease

46. __is a type of education designed for individuals or the public at large to gain the knowledge,
skills, value, and attitudes necessary to promote, maintain, improve, and restore their, or another
person's, health.
E High school education
F College education
G Community education
H Prosperity education
I Health education
47. Which of the following are essential services of Assurance core function of public health:
a. Diagnose and investigate health problems and health hazards in the community.
b. Inform, educate, and empower people about health issues.
c. Enforce laws and regulations that protect health and ensure safety.
d. Mobilize community partnerships to identify and solve health problems.
e. Develop policies and plans that support individual and community health efforts.
48. Which of the following are essential services of Policy Development core function of public health:
a. Monitor health status to identify community health problems.
b. Diagnose and investigate health problems and health hazards in the community.
c. Inform, educate, and empower people about health issues.
d. Link people to needed personal health services and assure the provision of health care
when otherwise unavailable.
e. Assure a competent public health and personal health care workforce.
49. What is the main difference between Quality Assurance and Quality Improvement?
J Quality Assurance uses mainly a team approach
K Quality Improvement focuses on statistical outliers for improvements
L Quality Assurance and Quality Improvement is practically the same
M None of the above
50. What is the most important principle for Quality Improvement? Quality Improvement focuses on…
N Individual performers
O Routine measurement of performance
P Training of providers
Q System’s issues
T/F

Please indicate whether following activities represent Public health surveillance

1) Diagnosing whether a case of encephalitis is actually due to West Nile virus infection
2) Soliciting case reports of persons with symptoms compatible with SARs from local hospitals
3) Creating graphs of the number of dog bites by week and neighborhood
4) Writing a report on trends in seat belt use to share with the state legislature
5) Disseminating educational materials about ways people can reduce their risk of Lyme disease

Please indicate true or false for following statements:

6) A cohort may be defined based on behavioral characteristics

7) Cohort studies are time-consuming to conduct
8) Cohort studies are inexpensive
9) The denominator for a measure of occurrence in a cohort study is always person-time since the
study participants are followed through time.
10) The study population in a cohort study can be very large
11) The study population in a cohort study cannot be dynamic (changing over time)
12) Cross-sectional studies can be used to study a chronic health outcome lacking information on time
of onset.
13) Cross-sectional studies can be used to evaluate the risk of a population with the health outcome
or risk factor of interest
14) Aggregate level data can provide information on the average exposure of the group, but not of
individuals
15) Aggregate level data can link exposures and other risk factors to those who became diseased and
those who did not
16) A reduction of incidence in the population screened is a possible outcome measure that could be
used as an indicator of the benefit of screening programs aimed at early detection of disease.
17) A causal pathway can be either direct or indirect.
18) A major difference in a case-control study and a cohort study is that the case-control study starts
with exposed study subjects and the cohort study starts with study subjects who have the disease.
19) A potential bias in using group data in Outcomes Research includes self selection.
20) Biases reflect inadequacies in the design or conduct of a study and clearly affect the validity of the
findings.
21) Confounding and bias are both examples of random error.
22) Confounding is defined as follows: when the incidence rate of disease in the presence of two or
more risk factors differs from the incidence rate expected to result from their individual effects.
23) Disease develops in everyone exposed to an environmental exposure.
24) Epidemiologic study investigators have an obligation to balance the rights of the individual and the
welfare of society.
25) Exposure must always occur before the disease it causes.
26) If a factor is necessary but not sufficient to cause a disease, then the disease cannot occur without
the factor.
27) If an association is found between the incidence of a disease and a certain genetically determined
characteristic, genetic factors are implicated in at least some cases of the disease.
28) In a case control study, relative risk can be calculated directly.
29) In a cohort study, the relative risk can be calculated directly.
 30) Meta-analysis: The statistical analysis of a large collection of analysis results from individual
studies for the purpose of integrating the findings. It increases statistical power and can give an
overall perspective when studies disagree.
31) It is sometimes hard to establish a temporal relationship between exposure and disease if the
study design is a retrospective cohort design.
32) Most causal relationships that operate in chronic diseases have identifiable primary cause.
33) Most of the issues that arise in the evaluation of health services are similar to those we see in
etiologic studies
Please indicate T/F whether indirect transmission includes an item below?
34) Droplet spread
35) Mosquito-borne
36) Foodborne
37) Doorknobs or toilet seats

Questions 38-40 are based on following information: Subjects from families with genetic disorders were
asked whether they had encountered problems when applying for life insurance. A sample from the
general population was also asked the same question (Low L et al. BMJ 1998; 317: 1632-1635). About a
third of respondents in the study group (723/2167) reported problems compared with only 5% of the
general population. This difference was significant at the 0.01% level. Please indicate whether following
statements are true or false.
38) A suitable null hypothesis would be that subjects from families with genetic disorders in the
population are more likely to experience problems when applying for life insurance than those
from the general population.
39) We can reject the null hypothesis at the 5% level of significance.
40) The result is significant at the 0.01% level. This means that we are 0.01% certain that the null
hypothesis is true.
 Gaps
1) Epidemiology is the study of the _______ and determinants of health-related states or events in
specified populations, and the application of this study to the control of health problems.

Questions 2-6 are based on following data:

In order to estimate counts and rates of work-related fatalities, the National Traumatic Occupational
Fatality system has introduced a tick-box on the death certificate to indicate "injury at work." Kraus et al.
(Am J Epidemiol 1995; 141: 973-9) attempted to validate this "injury at work" classification system against
a gold standard [International Classification of Diseases (ICD) death certificate codes designating deaths
that occurred during work-related activities]. After reviewing a sample of 100,000 death certificates, the
authors reported the following: 1,195 true positives; 788 false positives; 97,672 true negatives; 345 false
negatives. ("positive" indicates that the tick-box was checked; "negative" indicates that it was not
checked; "true" indicates agreement between the tick-box and the ICD code).

2) Using the counts provided above, complete the 2x2 table below:

ICD Classification
Death Certificate Work-related Not work-related TOTAL
Work-related
Not work-related
TOTAL
3) Calculate sensitivity of the "injury at work" classification system?

4) Calculate specificity of the "injury at work" classification system?

5) What is the positive predictive value? In your own words, how would you interpret this value?

6) Based on these data is the death certificate "injury at work" classification system likely to
underestimate or overestimate the true number of work-related fatal injuries?

7) 6729 men between the ages of 50 and 75 years of age with an elevated PSA and negative baseline
prostate biopsies were randomized to treatment with dutasteride 0.5 mg or placebo daily. Over
the entire 4-year study period, 659 of the 3305 men in the dutasteride group and 858 of the 3424
men in the placebo group were found to have prostate cancer. Relative risk reduction for the
development of prostate cancer of 22.8% (95% CI: 15.2-29.8; P < 0.001) for patients taking
dutasteride compared to patients taking placebo.1
Interpret results for educated reader without any medical or public health training

8) ____ is a non-causal association between an exposure and outcome due to the influence of a third
variable.
9) According to WHO definition health is a state of complete _____, mental, and social well-being.
10) The three core functions of public health are ___________, Policy Development, and Assurance

1
Andriole GL, Bostwick DG, Brawley OW, Gomella LG, Marberger M, Montorsi F, et al. Effect of dutasteride on the
risk of prostate cancer. N Engl J Med. 2010;362:1192–202.