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IHP 330 Principles of Epidemiology Case Study 2: Standardization Title: Standardization of Lung Cancer Deaths Objectives: Understand the use of standardizing rates to avoid confounding. Describe the terms stratification/stratum, standardization, standard population, and expected deaths. Calculate direct and indirect standardizations. Assignment (10 points) Read the following scenario and answer the corresponding questions to the best of your ability. For equation questions, please show your work. For multiple choice or true/false questions, please choose the best answer. For short-answer questions, please do your best to answer all parts of the question, but also consider the length of your answer and try to be brief. Be sure to check your work, and show evidence for your answers when necessary. Introduction Lung cancer is one of the main causes of mortality among adults in the United States, and the leading form of cancer mortality among men and among women. In 2012, there were more deaths from lung cancer (about 160,000) than colon, breast, pancreatic, and prostate cancer combined (ALA, 2013). As with all cancers, age plays a factor with incidence and mortality. Questions Question 1 (1 point): Interpret the following chart (Table 1) by describing in words what the numbers and indicators represent. Describe what is happening in both populations. Table 1: Questions 1 and 2; Lung Cancer Age group # deaths Population 25-34 303 40,873,139 35-44 2,709 42,467,719 45-54 12,356 31,078,760 Total 15,368 114,419,618 Rate per 100,000 per year IHP 330 Principles of Epidemiology Case Study 2: Standardization Answer: Question 2 (1 point): Calculate the age-specific death rates for Table 1. Table 1: Questions 1 and 2; Lung Cancer Age group # deaths Population 25-34 303 40,873,139 35-44 2,709 42,467,719 45-54 12,356 31,078,760 Total 15,368 114,419,618 Rate per 100,000 per year Question 3 (1 point): Complete the following table (Table 2) utilizing direct standardization. Table 2: Questions 3 and 4; Expected Lung Cancer Deaths Country A Country B Age group Standard Population Rate per 1,000 per year 0-24 11,000 1.94 2.31 25-49 17,000 5.45 7.14 50-74 20,000 41.11 36.36 75+ 3,000 83.33 95.00 Total 51,000 Age Adjusted Rate: Expected deaths Rate per 1000 per year Expected deaths IHP 330 Principles of Epidemiology Case Study 2: Standardization Comparative Mortality Ratio B:A: Question 4 (1 point): Describe what Table 2 means. Answer: Question 5 (1 point): Complete Table 3 utilizing direct standardization. Table 3: Questions 5, 6 and 7; Expected Lung Cancer Deaths in A and B Country A Country B Age group Country A Rate per 1,000 per year Population Expected deaths Population 0-24 1.94 1,100,000 7,025,000 25-49 5.45 5,000,000 10,500,000 50-74 41.11 5,500,000 9,800,000 75+ 83.33 1,750,000 3,900,000 Expected deaths Total Expected Deaths Total Observed Deaths 401,316.5 912,886 Standardized Mortality Ratio (SMR) Question 6 (1 point): Describe what Table 3 means. Answer: Question 7 (1 point): Why are the expected and observed deaths for Country A the same number in Table 3? Answer: Question 8 (2 points): The research needed to sufficiently prove that smoking causes lung cancer was a long, tough fight for health professionals and epidemiologists. From what you know about Hill's Criteria for Causation, which criteria can you assume are met IHP 330 Principles of Epidemiology Case Study 2: Standardization from the data shown in this case study and the understanding that older people and longer-term smokers have higher mortality rates than younger generations? Why? Answer: Question 9 (1 point): Is it possible to use direct and/or indirect standardization for indicators other than age, such as gender? More men are diagnosed with lung cancer than women every year, so would it be possible to find an adjusted rate and standardized mortality ratio using gender strata rather than age? Why? In addition to your written answer, you may draw a table using fake data to further your point. Answer: Reference: ALA (2013). Lung Cancer Fact Sheet. American Lung Association, updated 2013, available at http://www.lung.org/lung-disease/lung-cancer/resources/facts-figures/lung-cancerfact-sheet.html accessed 1 June 2013. IHP 330 Principles of Epidemiology Case Study 3: Outbreak Investigation Title: Outbreak Investigation Objectives: Understand the components of an outbreak investigation. Identify the types of outbreaks and vectors for disease. Calculate attack-rate. Interpret outbreak information into epidemiological practice. Assignment (10 points) Read the following scenario and answer the corresponding questions to the best of your ability. For equation questions, please show your work. For multiple choice or true/false questions, please choose the best answer. For short-answer questions, please do your best to answer all parts of the question, but also consider the length of your answer and try to be brief. Be sure to check your work, and show evidence for your answers when necessary. Introduction An epidemiologist for Georgia's Department of Public Health is alerted to an increase in emergency room and primary care-reported visits for severe gastroenteritis in a period of three days in and around a suburb of Atlanta, GA (100 cases in 3 days compared to a normal 25 cases in a week). Nearly all cases reported living in Atlanta or nearby suburbs; however there were a few cases who were residents of states around the country. Many of these out-of-state patients reported having lived in the Atlanta area in their youth. The epidemiologist decided that the sudden increase in severe gastroenteritis cases warranted an investigation. She developed a case definition for what she would investigate and alerted local hospitals and doctors to be aware of the presumed outbreak. She then interviewed cases whom she could contact to get a description of their recent actions and behaviors (if they could remember them) to piece together any common threads. It seemed that 85% of the cases available for interview had attended a high school reunion in the area. No cases could remember having been in contact with people demonstrating influenza symptoms recently, but all who attended the reunion had eaten food at the event. Questions Question 1 (1 point): Name and describe the modes of transmission of infectious disease. Which one do you think is the most likely cause of illness based on the information provided in the introduction? IHP 330 Principles of Epidemiology Case Study 3: Outbreak Investigation Answer: After her interviews were over, the epidemiologist graphed the cases of gastroenteritis with their time of onset of disease symptoms. The graph is below. Number of cases 40 35 30 25 Number of cases 20 15 10 5 0 0 5 10 15 20 25 30 35 40 45 50 55 60 Question 2 (1 point): Look at the above graph. What does the line of the trend within the graph indicate? What type of outbreak is this according to epidemic curve? Why? Answer: Question 3 (1 point): Create a case-definition for this outbreak. How would you define a case? Answer: About 500 people attended the high school reunion in question; 400 were graduates, and 100 were partners or spouses attending with a graduate. The epidemiologist was able to get in touch with 125 people from the event75 cases referred from hospitals and doctors and 50 non-symptomatic attendees referred by the organizers. Using their memory of the event and a report from the catering company, the epidemiologist was able to identify the suspected cause of the issues as crab cakes. She confirmed 74 of the 75 sick cases ate the crab cakes. Of the non-sick people she could interview, only 22 ate the crab cakes. She alerted the catering company and their food distributor to the issue with the crabcakes, had the organizers send out a warning about the exposure to a pathogen via IHP 330 Principles of Epidemiology Case Study 3: Outbreak Investigation food and to be vigilant about hand washing, and reported the incident to her department. Eventually, the reports of severe gastroenteritis returned to numbers she was used to seeing in Georgia as a whole. Question 4 (1 point): What is the attack rate of the illness? (Show your calculations.) Answer: Question 5 (1 point): Describe in a sentence or two what the attack rate means using the numbers from your calculations. Answer: Question 6 (2 points): Did the epidemiologist follow the steps of investigation for an infectious disease outbreak? Describe by filling in the steps below with the action she took (or did not take). If you believe there was a better, safer, or more efficient way to address the steps of outbreak investigation than was described in the scenario, also include what you would have done. Steps of Investigation: 1. 2. 3. 4. 5. Define the problem. Appraise existing data. Formulate a hypothesis. Confirm the hypothesis. Draw conclusions and formulate a practical application. Answer: Question 7 (1 point): Is this an epidemic? A pandemic? Why or why not? Answer: Question 8 (2 points): If the gastroenteritis symptoms continued to spread in the Atlanta area, what would you assume is occurring in the outbreak and vector for disease? Answer: IHP 330 Principles of Epidemiology Case Study 2: Standardization Title: Standardization of Lung Cancer Deaths Objectives: Understand the use of standardizing rates to avoid confounding. Describe the terms stratification/stratum, standardization, standard population, and expected deaths. Calculate direct and indirect standardizations. Assignment (10 points) Read the following scenario and answer the corresponding questions to the best of your ability. For equation questions, please show your work. For multiple choice or true/false questions, please choose the best answer. For short-answer questions, please do your best to answer all parts of the question, but alsoconsider the length of your answerand try to be brief. Be sure to check your work, and show evidence for your answers when necessary. Introduction Lung cancer is one of the main causes of mortality among adults in the United States, and the leading form of cancer mortality among men and among women. In 2012, there were more deaths from lung cancer (about 160,000) than colon, breast, pancreatic, and prostate cancer combined (ALA, 2013). As with all cancers, age plays a factor with incidence and mortality. Questions Question 1 (1 point):Interpret the followingchart (Table 1) by describing in words what the numbers and indicators represent. Describe what is happening in both populations. Table 1: Questions 1 and 2; Lung Cancer Age group # deaths Population 25-34 303 40,873,139 35-44 2,709 42,467,719 45-54 12,356 31,078,760 Total 15,368 114,419,618 Rate per 100,000 per year IHP 330 Principles of Epidemiology Case Study 2: Standardization Answer: the table shows the number of deaths occurring between the ages highlighted out of the total number of people in that age group in one year. #deaths- indicating the total number of deaths that happen in an age group within one year #population- indicating the total number of people in the age group that in an year. Question 2 (1 point):Calculate the age-specific death rates for Table 1. Table 1: Questions 1 and 2; Lung Cancer Age group # deaths Population 25-34 35-44 45-54 Total 303 2,709 12,356 15,368 40,873,139 42,467,719 31,078,760 114,419,618 Rate per 100,000 per year 0.741318155 6.378962807 39.75705594 13.43126316 Question 3 (1 point):Complete the following table (Table 2) utilizing direct standardization. Table 2: Questions 3 and 4; Expected Lung Cancer Deaths Country A Age group 0-24 25-49 50-74 75+ Country B Standard Population Rate per 1,000 per year Expected deaths 11,000 17,000 20,000 3,000 1.94 5.45 41.11 83.33 21.34 92.65 822.2 249.99 Rate per 1000 per year 2.31 7.14 36.36 95 Expected deaths 25.41 121.38 727.2 285 IHP 330 Principles of Epidemiology Total 51,000 Age Adjusted Rate: Case Study 2: Standardization 131.83 1186.18 23.25843137 140.81 1158.99 22.72529412 Comparative Mortality Ratio B:A: =0.977078 Question 4 (1 point):Describe what Table 2 means. Answer: the above table means that, with the age groups given and the populations given, the rate of death per 1000 people is the one indicated meaning that the number of expected deaths is the one calculated. For the age adjusted rate, it is the average number of expected deaths. Question 5 (1 point):Complete Table 3 utilizing direct standardization. Table 3: Questions 5,6and7; Expected Lung Cancer Deaths in A and B Age group Countr y A Rate per 1,000 per year 0-24 1.94 25-49 5.45 50-74 41.11 75+ 83.33 Total Expected Deaths Total Observed Deaths Standardized Mortality Ratio(SMR) Country A Population 1,100,000 5,000,000 5,500,000 1,750,000 401316.5 Expected deaths 2134 27250 226105 145827.5 Country B Population 7,025,000 10,500,000 9,800,000 3,900,000 798718.5 Expected deaths 13628.5 57225 402878 324987 401,316.50 1 912,886 1.142938344 Question 6 (1 point): Describe what Table 3 means. Answer: the number of observed deaths in country A divided by the number of expected deaths in country A is equal to 1 IHP 330 Principles of Epidemiology Case Study 2: Standardization The number of observed deaths in country B divided by the number of expected deaths in country B is equal to 1.142938344 Question 7 (1 point):Why are the expected and observed deaths for Country A the same number in Table 3? Answer: this is because Question 8 (2 points): The research needed to sufficiently prove that smoking causes lung cancer was a long, tough fight for health professionals and epidemiologists. From what you know about Hill's Criteria for Causation, which criteria can you assume are met from the data shown in this case study and the understanding that older people and longer-term smokers have higher mortality rates than younger generations? Why? Answer: consistency- we assume that many studies have been done to prove that smoking causes cancer. This is because one result cannot lead us to concluding that smoking causes cancer. Question 9 (1 point):Is it possible to use direct and/or indirect standardization for indicators other than age, such as gender? More men are diagnosed with lung cancer than women every year, so would it be possible to find an adjusted rate and standardized mortality ratio using gender strata rather than age? Why? In addition to your written answer, you may draw a table using fake data to further your point. Answer: yes it is possible since sex will also subdivide the data into two entities. Reference: ALA (2013). Lung Cancer Fact Sheet. American Lung Association, updated 2013, available at http://www.lung.org/lung-disease/lung-cancer/resources/facts-figures/lung-cancerfact-sheet.html accessed 1 June 2013. IHP 330 Principles of Epidemiology Case Study 3: Outbreak Investigation Title: Outbreak Investigation Objectives: Understand the components of an outbreak investigation. Identify the types of outbreaks and vectors for disease. Calculate attack-rate. Interpret outbreak information into epidemiological practice. Assignment (10 points) Read the following scenario and answer the corresponding questions to the best of your ability. For equation questions, please show your work. For multiple choice or true/false questions, please choose the best answer. For short-answer questions, please do your best to answer all parts of the question, but alsoconsider the length of your answer and try to be brief. Be sure to check your work, and show evidence for your answers when necessary. Introduction An epidemiologist for Georgia's Department of Public Health is alerted to an increase in emergency room and primary care-reported visits for severe gastroenteritis in a period of three days in and around a suburb of Atlanta, GA (100 cases in 3 days compared to a normal 25 cases in a week). Nearly all cases reported living in Atlanta or nearby suburbs; however there were a few cases who were residents of states around the country. Many of these out-of-state patients reported having lived in the Atlanta area in their youth. The epidemiologist decided that the sudden increase in severe gastroenteritis cases warranted an investigation. She developed a case definition for what she would investigate and alerted local hospitals and doctors to be aware of the presumed outbreak. She then interviewed cases whom she could contact to get a description of their recent actions and behaviors (if they could remember them) to piece together any common threads. It seemed that 85% of the cases available for interview had attended a high school reunion in the area. No cases could remember having been in contact with people demonstrating influenza symptoms recently, but all who attended the reunion had eaten food at the event. Questions Question 1 (1 point):Name and describe the modes of transmission of infectious disease. Which one do you think is the most likely cause of illness based on the information provided in the introduction? IHP 330 Principles of Epidemiology Case Study 3: Outbreak Investigation Answer: Body contact- contact with an infected people. Air borne- transmitted via air. Most probable mode of transmission is contact with infected people, that why all the people infected were from Atlanta or had spent their youth in Atlanta meaning that they might have visited their families in the near past. After her interviews were over, the epidemiologist graphed the cases of gastroenteritis with their time of onset of disease symptoms. The graph is below. 40 35 30 25 20 Number of cases 15 10 5 0 0 5 10 15 20 25 30 35 40 45 50 55 60 Question 2 (1 point):Look at the above graph. What does the line of the trend within the graph indicate? What type of outbreak is this according to epidemic curve? Why? Answer: many cases were reported between 5 and 25. This suggests that this is a epidemic outbreak because it was more infectious between 5 and 25 and affected only people in Atlanta or those who are from there. Question 3 (1 point):Create a case-definition for this outbreak. How would you define a case? Answer: infected individuals demonstrated signs of diarrhea and vomiting. They were all from the Atlanta or had lived in Atlanta. The symptoms were reported within a week. About 500 people attended the high school reunion in question; 400 were graduates, and 100 were partners or spouses attending with a graduate. The epidemiologist was able to get in touch with 125 people from the event75 cases referred from hospitals and doctors and 50 non-symptomatic attendees referredby the organizers. Using their memory of the event and a report from the catering company, the epidemiologist was IHP 330 Principles of Epidemiology Case Study 3: Outbreak Investigation able to identify the suspected cause of the issues as crab cakes.She confirmed 74 of the 75 sick cases ate the crab cakes. Of the non-sick people she could interview, only 22 ate the crab cakes. She alerted the catering company and their food distributor to the issue with the crabcakes, had the organizers send out a warning about the exposure to a pathogen via food and to be vigilant about hand washing, and reported the incident to her department. Eventually, the reports of severe gastroenteritis returned to numbers she was used to seeing in Georgia as a whole. Question 4 (1 point):What is the attack rate of the illness? (Show your calculations.) Answer: 74/75*100= 98.66667 % Question 5 (1 point):Describe in a sentence or two what the attack rate means using the numbers from your calculations. Answer: it is the number of people in affected out of the number of people exposed to the virus. This is done by dividing the number of people affected by the whole population exposed. Question 6 (2 points):Did the epidemiologist follow the steps of investigation for an infectious disease outbreak? Describe by filling in the steps below with the action she took (or did not take). If you believe there was a better, safer, or more efficient way to address the steps of outbreak investigation than was described in the scenario, also include what you would have done. Steps of Investigation: 1. Define the problem2. Appraise existing data- she collected the data about the reunion party and all the people who attended it. 3. Formulate a hypothesis- she noted that the infected patients may have eaten the crab cakes. 4. Confirm the hypothesis- she confirmed that 74 out of the 75 had attended the reunion party and ate the crab cakes. 5. Draw conclusions and formulate a practical application.- she realized that the crab cakes were the mode of transmission. She therefore informed the catering company about the issue. Answer: Question 7 (1 point):Is this an epidemic? A pandemic? Why or why not? IHP 330 Principles of Epidemiology Case Study 3: Outbreak Investigation Answer: epidemic because it affected only a small number of people who attended the reunion party and affected them at the specified time. It is not a pandemic since it never spread to other lacations and continents. Question 8 (2 points):If the gastroenteritis symptoms continued to spread in the Atlanta area, what would you assume is occurring in the outbreak and vector for disease? Answer: we would assume that gastroenteritis was air borne and the people who were initially affected by visiting Atlanta later spread it to other areas through the air