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Exam Observational epidemiology, CIH 2008

Question 1
Assume that you are planning a survey on the prevalence of an infection and have calculated
that you will need a sample size of 1000. In that calculation you assumed simple random
sampling. However, you ended up with a cluster sampling approach, and were told that the
design effect (DEFF) for this type of survey could be about 1.8.

1.1 (3 points) What would you suggest the sample size to be?

1.2 (2 points) When analysing your data (from the survey applying cluster sampling) you are
supposed to “take into account” the design effect. Compared to an analysis assuming simple
random sampling, how is this likely to influence the
- point estimate and
- the precision (confidence interval)?

Question 2
2.1 (4 points) In surveys we often have to construct and apply sample weights when
estimating a prevalence.
Give an example of a sampling approach (or sampling design) where it will be necessary to
apply weights.

2.2 (4 points) Give an example of a sampling approach where it will not be necessary to
apply weights (be self-weighting)

Question 3 (3 points)
Systematic error (bias) can cause substantial inaccuracy in estimates. There are two major
categories of bias, selection bias and information bias (also called misclassification). Explain
briefly the difference between these two categories and illustrate by examples.

Question 4
Information about sample size, response and prevalence of HV2 (Herpes Virus type2) in a
survey among a group of people aged 15-29 years is given in Table 1. As you can see from
this information, the proportion of responders differed by age-group (differential non-
response).

Table 1. Results from a survey on HV2 (herpes virus 2): sample size, number of participants
and prevalence of HV2 given by age-group.
Age-group Number in the Number of Prevalence (%)
sample respondents
15-19 400 350 2
20-24 300 240 15
25-29 300 120 20
15-29 1000 710 9.4 (crude)

4.1 (5 points)
Adjust the crude HV2 prevalence for differential non-response.
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4.2 (4 points) Compare the crude (the estimate based on all participants) with the adjusted
estimate. Which of the two are preferable to use when communicating the prevalence level for
the age-group 15-29 years? Explain briefly why.

4.3 (5 points) In the survey presented in Table 1 there was no information on to what extent
non-responders differed from responders with regards to HV2 prevalence. Let us here assume
that the prevalence ratio of non-responders versus responders was 1.5 (i.e. that non-responders
had 1.5 times higher prevalence).

Calculate the crude prevalence assuming that non-responders had a 1.5 times higher
prevalence compared to the survey participants.

The article “Exposure to Mosquito Coil Smoke May Be a Risk Factor for Lung Cancer
in Taiwan” by Shu-Chen Chen et al , J Epidemiol 2008; 18(1) 19-25 is the reference for
answering questions 5-11

Question 5 (2 points)
List 2 factors that may have contributed to selection bias in the study?

Question 6 (2 points)
“This interviewer was trained to treat patients and controls in a similar manner and was
masked to the participants’ group assignment” List 2 biases that were minimized by these
measures.

Question 7 (2 points)
Study Table 1 carefully. List 2 variables that you would have adjusted for and the reasons
why?

Question 8 (3 points)
Study Table 2 carefully. Calculate the Crude Odds Ratio and 95% Confidence Interval for the
overall MCS – lung cancer relationship.

Question 9 (3 points)
What evidence presented in this study suggests that MCS is a possible cause of lung cancer in
Taiwan? Give reasons.

Question 10
In a follow-up study to examine the relationship between physical activity and myocardial
infraction (MI), the following results were observed after 12 years of follow-up:

Physical Number at start of Number of Number of cases of

activity follow-up responders lost to MI diagnosed among
follow-up the responders during
follow-up
Total Responders
High 2.250 216 32
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Moderate 4.500 740 78

Low 3.250 820 110
Total 14000 10.000 1776 220

10.1 (3 points) Calculate the person-years at risk for all responders and for the subgroups
according to level of physical activity, assuming that the loss to follow-up and number of
cases diagnosed are evenly distributed during the 12 years of follow-up.

10.2 (3 points) Calculate the incidence rates per 10.000 person years for all responders and for
the subgroups of responders according to physical activity.

10.3 (2 points) Calculate the incidence rate ratio for the different sub-groups according to
physical activity, using the group reporting high physical activity as your reference.

10.4 (3 points) How might subclinical disease before start of follow-up have influences the
results of this study?

10.5 (3 points) How could you minimize or assess the effect of subclinical disease before start
of follow-up a) in the design of the study b) in the analyses of the study

10.6 (3 points) The total response rate in this study was 71.4 % and might have varied
between the subgroups. Is it likely that this might have caused a bias in your study? What are
the requirements that need to be full-filled if non-response would distort findings of
relationships between exposure and disease in follow-up studies?

Question 11 (3 points)
Loss to follow-up can distort results of cohort studies. What are the conditions under which
loss to follow-up can distort the results (e.g. rate ratios of effects of exposure)?

Question 12 (4 points)
How would you ensure that loss to follow-up is minimized in the planning and the execution
of a follow-up study?

Question 13 (4 points)
Explain what is meant by differential and non-differential misclassification and give
examples of how these two types of misclassification can influence results in cohort studies.