TUGAS

INTERMEDIATE EPIDEMIOLOGI
PRAKTIKUM EPIDEMIOLOGI 2
RANCANGAN STUDI

Rindu Rachmiaty
Tiersa Vera Junita
Novi Indriastuti

(NPM 1406594064)
(NPM 1406594101)
(NPM 1306428443)

PROGRAM PASCA SARJANA

FAKULTAS KESEHATAN MASYRAKAT
UNIVERSITAS INDONESIA
2014

RANCANGAN STUDI
I.

Studi Epidemiologi Deskriptif

I.1.
Studi kasus
I.2.
Studi Korelasi
I.3.
Studi Kros Seksional

II.
II.1.
II.2.
II.3.
II.4.
II.5.
1.

Studi Epidemiologi Analitik

Kasus Kontrol
Kohort
Uji Klinik
Uji Komunitas
Kuasi Eksperimental

Swaen et al (1998) conducted a study of 6,803 males who worked for at least
six months before 1/1/80 at one of nine chemical plants in the Netherlands. The
workers were followed for mortality from 1/1/56 until 1/1/96. Before 1/1/80, 2,842
of the workers were occupationally exposed to acrylonitrile and the other 3,961
workers were not exposed to acrylonitrile. After 1/1/80, there was no exposure to
acrylonitrile. To measure the association between occupational exposure to
acrylonitrile and several outcomes, the investigators calculated standardized
mortality ratios (SMRs) for both the exposed and the unexposed workers. Ageinterval-specific person-years were generated for specific exposure groups and
were multiplied by the mortality rates for the total male population of the
Netherlands to generate expected numbers of cause specific deaths.
a.

What study design did the investigators use? (2 pts)

Studi kohort

b.

What was the (crude) cumulative incidence ratio (CIR) for mortality
comparing the exposed to the unexposed men?
CIR = 2842 = 0,72
3961
CIR = RR, RR < 1 artinya ada hubungan dan penurunan risiko

c.

What are two reasons why this measure is problematic with these data?
Data hanya menunjukkan akumulasi exposure sebelum tahun 1980,
tidak menunjukkan jumlah exposure per tahun sehingga tidak bisa
menghitung insiden rate

d.

For brain cancer, the SMR for the exposed workers (SMR = 173.9) was
more than twice the SMR for the unexposed workers (SMR = 85.7). Why are
these two SMRs not strictly comparable? (3 pts)
distribusi interval usia exposed dan not exposed mungkin berbeda.

e.

There were 290 deaths due to all causes among the exposed group and
983 deaths due to all causes among the unexposed group. What
measure of effect could be calculated to strictly compare all-cause mortality
between the exposed and the unexposed group. (2 pts)

Exposed
Non exposed
Total

(+)
290
983
1273

(-)
2552
2978
5530

Total
2842
3961
6803

Pengukuran yang efektif untuk membandingkan penyebab kematian

antara kelompok exposed dan unexposed adalah
2.

Suppose that in 1998 researchers hypothesized that communication ability

and skill in young adulthood was related to Alzheimers Disease. To test this they
evaluated hand written essays completed by a group of 350 nuns joining a single
religious sect in 1930. By careful review of these writing samples, the
researchers categorized all 350 as either having a high error profile (N = 150) or
a low error profile (N = 200). Using surveillance of death certificates and other
methods the researchers verified vital status of each nun through 1998. An
accounting of all deaths produced the table below.
Cause of Death and Year by Handwriting Profile Status
High error profile
Cause
Death

Low error profile

of #
of Year of Cause
Deaths
Death
Death

of #
of Year
of
Deaths
Death

Alzheimers
Disease

1980

Alzheimers
Disease

1985

Alzheimers
Disease

1985

Alzheimers
Disease

1990

Alzheimers
Disease

1990

Alzheimers
Disease

1995

Alzheimers
Disease

1995

18

8
Heart
Disease

1980

Heart Disease

10

1980

Heart
Disease

10

1990

Heart Disease

15

1995

Other

20

1960

Other

25

1960

Other

30

1970

Total

98

Other

10

1970

56

a. Describe the type of study design used in this example. (2 pts)

Studi cohort
b. Compute the incidence density rate of Alzheimers disease death for those
with a high error profile and for those with a low error profile. (3 pts) Show
your work.
High error profile

2 org
5 org
6 org
5 org
1930

1980 1985 1990 1995

ID = 2 + 5 + 6 + 5 =
18 orang / tahun
230
230
Low error profile

1 org
3 org
4 org
1930

1985

1990

1995

ID = 1 + 3 + 4 =
8 orang / tahun
180
180
c. Compute the incidence density ratio for the risk of Alzheimers disease
death associated with a high error communication profile. Explain, in two
sentences or less, what this value means. (3 pts)
IDR = ID high error profile
ID low error profile
IDR = 18 x 180 = 1,76
230
8

IDR > 1, artinya populasi dengan high error profile lebih berisiko meninggal
karena penyakit Alzheimer.
d. Using data from this study compute an odds ratio for the association of a
high error communication profile with death from Alzheimers disease.
Show a clearly labeled 2x2 table. (2 pts)
Alzheimer Alzheimer
(+)
(-)
18
80
8
48
26
128

High eror
Low eror
Total

Total
98
56
154

OR = 18 x 48 = 1,35
8 x 80
Artinya, pada populasi dengan high error profile memiliki peluang meninggal
karena penyakit Alzheimer 1,35 kali lebih besar dibandingkan dengan
populasi dengan low error profile.
e. Compare the odds ratio with the incidence density ratio computed in part
c and explain why they are similar or different.
IDR = RR = 1,76
OR = 1,35

3.

Suppose that a study was conducted to compare the rates of automobile

collisions in two cities. The researchers were impressed with studies that
suggest that the use of cell phones and pagers contribute to auto collisions.
They wanted to adjust (standardize) the rates of auto collisions in the two cities
for cell phone and pager use. Data on cell phone use and auto collisions in the
two cities were collected and are presented in the table below.

Cell phone and

pager use

Corona del Mar, California

#
persons

#
accidents

Heavy

4479

Moderate

Rate*

Boulder, Colorado

#
persons

#
accidents

293

100

974

27

300

Never

1106

15

8293

145

Total

6559

335

8693

153

Rate*

* per 1000 persons

4.

a.

Calculate the crude total and cell phone/pager use specific rates for Corona
del Mar and Boulder. How do these two cities compare in crude prevalence
of auto accidents. (2 pts)
Crude accident rate Corona del Mar = 335/6559 x100 = 51,1/1000
Crude accident rate Boulder = 153/8693 x 100 = 17,6/1000
Ratio = 51,1/17,7 = 2,9
Crude accident rate Corona del Mar 2.9 lebih tinggi daripada di
Boulder.

b.

Using the combined number of persons in both areas as a standard,

calculate a standardized rate (standardized for cell phone/pager use) for
each of the states. Use the direct standardization method. Briefly describe
how these standardized rates compare with each other and with the crude
rates. Briefly describe any meaningful differences. (4 pts)
Adjusted rates
Corona del Mar: (4579 x 0,0654) + (1274 x 0,0277) + (9399 x 0,0136) /
15,252 = 29.9/1000
Boulder: (4579 x 0,0200) + (1274 x 0,0200) + (9399 x 0,0178) /15,252 =
18.6/1000
Penggunaan ponsel / pager menyebabkan tingkat kecelakaan di Corona del
Mar 1,6 kali lebih tinggi daripada di Boulder.

c.

In general, describes a major weakness of both crude and adjusted rates?

(2 pts)
Both measures obscure heterogeneity (variation) in rates across
subgroups.

Rothmans has proposed that "public health synergism" is present when an

observed joint effect exceeds that expected under the additive model. Do the
odds ratios in Table 3 indicate the presence of "public health synergism" for
effect of Heberden's nodes and elevated body mass index on hip osteoarthiritis?
If not, do the odds ratios conform to a multiplicative model? Include in your
answer a 1-2 sentence assessment of whether these data indicate "public health
synergism". (For this question, ignore the row for "Possible" Heberden's nodes
and the column for the middle tertile of body mass index, and assume that both
Heberdens nodes and elevated BMI reflect casual risk factors for hip
osteoarthritis. Note: do not necessarily rely on the authors' description of this
table.) (6 pts)
Odds ratios for hip
osteoarthiritis
Heberden's nodes
None
Possible

Body mass index

Lowest third

Middle third

Highest third

1.0

1.1 (0.7-1.8)*

1.6 (1.0-2.7)

1.5 (0.8-2.7)

1.5 (0.8-2.6)

2.0 (1.1-3.6)

Definite

1.4 (0.9-2.3)

2.2 (1.4-3.7)

3.2 (1.9-5.4)

* Numbers in parentheses, 95% confidence interval.

a.

Which estimate indicates a stronger association? (2 pts)

OR hip osteoarthritis dengan definite heberdens nodes dan highest third BMI
= 3,2 semakin besar nilai OR semakin kuat asosiasinya.

b.
c.

5.

Which estimate is more precise? (2 pts)

Which estimate is more compatible with a population odds
ratio of 4.0? (2 pts)
OR hip osteoarthritis dengan definite heberdens nodes dan highest third BMI
= 3,2 (1,9 5,4) nilai ini lebih compatible karena OR = 4 masuk dalam
range.

The authors investigated the association of specific sporting activities with risk
of hip osteoarthritis. Their data are presented in Table below. Using their data,
compute separately the unadjusted (crude) risk of osteoarthritis associated with
playing golf and for swimming in men and women combined. Consider those
who do not participate in any sport as the reference group and assume no
missing data. Show two appropriate 2x2 table and your calculations. (4 pts)
Golfers

Cases

Controls

YES

51

34

NO

140

162

OR = 51 x 162 = 1,74
140 x 34

Swimming

Cases

Controls

YES

156

110

NO

140

162

OR = 156 x 162 = 1,64

140 x 110
a.

Briefly list two reasons why a case control study is (or is not) appropriate to
examine individual risk factors for hip osteoarthritis. (2 pts)
Sesuai dengan studi case control karena kasus jarang dan banyak
exposure yang terlibat.

6.

b.

The authors state that their cases come from a defined population. List four
features of the population or the study design that support this statement or
helped the authors to achieve it? (4 pts)

c.

The odds ratio (95% confidence interval) estimating the risk of osteoarthritis
associated with a previous hip injury was 24.8 (3.1-199.3) in men and 2.8
(1.4-5.8) in women (see Table ).

d.

Compare these unadjusted (crude) odds ratios with the ones presented in
Table 3. Briefly describe and explain the comparison. (3 pts)

e.

Consider the possibility that golfers who have hip osteoarthritis are reluctant
to seek medical attention for their condition for fear it will mean the end of
their ability to play golf. Therefore, cases who golf are less likely to be
selected for this study than cases who do not golf. If the true OR associated
with golf is 2.0, then describes the selection bias and its impact on the odds
ratio you computed. (3 pts)

The authors state that "...the association with swimming may have arisen
because patients with hip osteoarthritis were advised to swim..." . Suppose that
25% of the cases had been incorrectly classified as swimmers and assume that
the misclassified cases had not participated in any other sporting activity, either.
Re-compute the odds ratio for the association of hip osteoarthritis and
swimming, after re-classifying these individuals, using the number from the 2x2
table in question 19 above. Briefly discuss how your conclusion about the role of
swimming does (or does not) change. In what direction did misclassification bias
the study OR? (3 pts)
Swimming

Cases

Controls

YES

156-25% = 117

110

NO

140 + 39 = 179

162

OR = 0.96: The misclassification was differential and biased the odds ratio
upward.
The odds ratio (95% confidence interval) estimating the risk of osteoarthritis
associated with a previous hip injury was 24.8 (3.1-199.3) in men and 2.8 (1.45.8) in women .
a. Which estimate indicates a stronger association? (2 pts)
Men nilai OR laki-laki (24,8) lebih besar dari OR perempuan (2,8)
b.

Which estimate is more precise? (2 pts)

Woman range nilai OR perempuan tidak seluar rang nilai OR laki-laki

c.

7.

Which estimate is more compatible with a population odds ratio of 4.0? (2

pts)
Woman

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. The following
table presents the number of cases of age-related maculopathy measured at the
follow-up examination among the 1232 male participants ages 43-86 who did not
have age related maculopathy (ARM) at the baseline examination:
Smoking status

Cases of ARM

Never smokers

368

26

Ever smokers

864

79

a.

Describes the research design used by in this study?

Studi cohort (prospektif)

b.

Create a 2 x 2 table where one axis is smoking status and the other is agerelated maculopathy status. (4 pts)
ARM
ARM
Total
(+)
(-)
Smoking
79
785
864
No smoking
26
342
368
Total
105
1127
1232

c.

Calculate the 5-year cumulative incidence of age-related maculopathy in

ever smokers, and in never smokers. Show your work. (4 pts)
CI smoker = 79 = 0,09
864
Artinya, risiko terjadinya ARM pada populasi merokok selama 5 tahun
adalah 0,09
CI non smoker =

26 = 0,07

368
Artinya, risiko terjadinya ARM pada populasi tidak merokok selama 5 tahun
adalah 0,07
d.

Calculate the cumulative incidence ratio comparing the incidence of agerelated maculopathy in ever smokers with that in never smokers. Show your
work. (4 pts)
CIR = CI smoker

CI non smoker
CIR = 0,09 = 1,28
0,07
CIR = RR, RR > 1 artinya populasi yang merokok lebih berisiko ARM
e.

8.

Assuming causality, what is the proportion of cases of age-related

maculopathy that could have been prevented in the population of males
ages 43-86 in Beaver Dam if the smokers had never smoked? Show your
work. (4 pts)
Proporsi ARM pada smoker = 26 x 100% = 7,1%
368
Jika semua populasi tidak merokok, maka jumlah kasus ARM yang dapat
dicegah adalah 7,1% x 1232 = 87 kasus

The following data come from a national survey of the occurrence of

back pain. A case of low back pain was defined as having at least one episode of
severe back pain occurring over a period of 6 months. The number of cases was
obtained from surveys of different occupation groups as well as a national
random sample.
Cell phone
manufacturing

Textile manufacturing

National random sample

Age

Persons

cases

Rate

Persons

Cases

Rate

Persons

Cases

rate

25-39

1000

.002

100

.02

10,000

30

.003

40-55

700

25

.037

500

30

.06

15,000

900

.06

55+

50

15

.300

1500

150

.100

15,000

1200

.08

Total

1750

42

.024

2100

182

.087

40,000

2130

.053

a.

Compute a standardized event ratio (similar to a standardized mortality ratio

(SMR) except the episodes of back pain arent mortal events) of back pain
for the cell phone-manufacturing employees. Briefly state in one sentence
the interpretation of this measure in this case. (3 pts)
Standardized event ratio (for cell phones) = SMR (cell phone) =
observed/expected
= 42/{(.003)(1000) + (.06)(700) + (.08)(50)} = 42/49 = 0.86

b.

Compute a standardized event ratio (similar to a standardized mortality ratio

(SMR) except the episodes of back pain arent mortal events) of back pain
for the textile-manufacturing employees. Briefly state in one sentence the
interpretation of this measure in this case. (3 pts)
Standardized event ratio (textiles) = SMR (textile) = observed/expected
= 182/{(.003)(100) + (.06)(500) + (.08)(1500)} = 182/150 = 1.2

10

c.

9.

Can these two ratios in part (a) and (b) be compared? Briefly explain why or
why not. (3 pts)

The evidence supporting obesity as a risk factor for colon cancer

remains inconclusive, especially among women. A recent 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
body
mass
index*

Number of
incident
cases of
colon cancer

Personyears
of follow up

Crude incidence rate/100,000 PY

<22

28

53,475

28/53475 x 100000 = 52,4 0/00

22 - <24

41

38,919

41/38919 x 100000 = 105,3 0/00

24 - <26

36

36,610

36/36610 x 100000 = 98,3 0/00

26 - <28

40

32,635

40/32635 x 100000 = 122,6 0/00

28 - <30

35

21,122

35/21122 x 100000 = 165,7 0/00

30+

42

34,904

42/34904 x 100000 = 120,3 0/00

Total

222

217,665

* kg body weight per height in meters squared

a.

Describes the research design used in this study? (choose one best
answer). (2 pts)
Studi cohort

b.

Complete the table by calculating the crude body mass index-specific

incidence rates. (3 pts).

c.

Calculate the relative risk (RR) of colon cancer associated with a BMI of 28<30. Use the lowest BMI category as referent. In one sentence interpret
your answer. (2 pts)
Baseline body
mass index*

Number of incident cases

of colon cancer

Person-years
of follow up

<22

28

53,475

11

22 - <24

41

38,919

24 - <26

36

36,610

26 - <28

40

32,635

28 - <30

35

21,122

30+

42

34,904

Total

222

217,665

RR = 35 x 21122 = 0,49
28 x 53475
RR < 1, artinya ada asosiasi antara BMI dengan insiden kasus kanker kolon
(penurunan risiko)
d.

Calculate the attributable risk proportion of those in the 28-<30 BMI

category. In one sentence interpret your answer. (the attributable risk
formulas provided in class can be used even though the data provide is for
rates) (2 pts)
Ine = 187/196543 x 100000 = 95,1 0/00
AR = Ie - Ine
= 165,7 - 95,1 = 70,6 0/00
Artinya

12