Epidemiological and

UNIT 3 EPIDEMIOLOGICAL AND Statistical Exercises

STATISTICAL EXERCISES
Structure

3.0 Objectives

3.1 Introduction

3.2 AFP Surveillance

3.3 Community Need Assessment

3.4 Birth Rate and General Fertility Rate

3.5 Statistical Charts

3.6 Basic Risk Estimates

3.7 Protective Efficacy of a Vaccine

3.8 Validity and Predictive Accuracy of a Screening Procedure

3.9 ABC-VED Analysis for a Medicine Store

3.10 Let Us Sum Up

3.11 Answers to the Exercises

3.0 OBJECTIVES
By the end of this unit you should be able to:

l respond rationally to a report of AFP case in your area;

l assess the community needs of RCH services;

l make suitable statistical charts from tabular data;

l compute basic risk estimates; protective efficacy of a vaccine; and validity as well as
predictive accuracy of a screening procedure; and

l perform ABC-VED analysis for a medicine store.

3.1 INTRODUCTION
In the preceding two units we have dealt with the practical aspects of immunization and
health education and counselling.

In the present unit we will create some important epidemiological and statistical situations
related to RCH and try to address them. While dealing with them, you will realize that these
situations are as nearer to the reality as possible. This will enable you to apply your
knowledge/skills in solving practical problems. In the course of this unit, you will cover a
broad area of practical epidemiology that shall include AFP surveillance, community need
assessment, statistical charts, basic risk estimates, protective efficacy; validity and
predictive accuracy, and ABC-VED analysis. Read the concerned theory material in MME-
101. If you still can not solve the exercises given in this unit, your counsellors at the PSC
will help to increase your practicability.

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Practical Manual
3.2 AFP SURVEILLANCE
Exercise 1

You are a private practitioner in Saharanpur. There is a slum in the vicinity of your clinic. A
suspected case of acute flaccid paralysis (AFP) has been reported to you by one of your
patients from this area. Considering it’s significance, you visit the locality and examine the
case. The case of AFP is confirmed. You notify the district immunization officer (DIO) or
surveillance medical officer (SMO) at the earliest.

a) You will also start arranging for?

1) ...............................................................................................................................................

2) ...............................................................................................................................................

3) ...............................................................................................................................................

b) 1) Stool specimens are to be collected within how many days of the onset of
paralysis?

2) How many stool specimens are to be collected?

3) What should be the time gap between the collection of the two specimens?

4) What amount of stool should be collected for each specimen?

5) How do you sterilize the specimen container?

6) What preservative/transport media is used for stool specimen?

Exercise 2

In a state ‘X’, there were a total of 132 cases of AFP in 2001. The lab results of adequate
stool specimens are available for 121 AFP cases. Wild polio virus could be isolated from 2
of them. Of the rest of the 11 AFP cases with inadequate stool specimens: 3 were lost to
follow-up; 1 died during follow-up; 2 had residual weakness; and 5 had no residual
weakness after 60 days. Finally, the expert group at national level discarded 3 cases after
reviewing the referred cases.

Fill the following table on the basis of above information:

Confirmed polio cases

Cases referred to Expert Group

at national level for the review

Polio Compatible AFP

Non-Polio AFP

3.3 COMMUNITY NEED ASSESSMENT

Exercise 3

You are MO I/c of PHC Ramnagar. The population of the sub-centre Balaghat in your area
is 6400. Health Worker (F) of the area has just started her annual community need
assessment for RCH services, through household survey and consultative process. The
Birth Rate and Infant Mortality Rate of your district are not available but at the state level
they are 22 and 68 respectively. Compute the following estimates for this sub-centre for
making comparison with the assessment of the health worker:
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 Epidemiological and
Sl.No. Expected RCH related events in the area Probable number Statistical Exercises

1. Pregnancies

2. Deliveries/live births

3. Ante-natal registration
(for requirement of ANC visits, IFA & TT doses)

4. High risk ante-natal cases

(for preparedness at PHC & FRU)

5. Pregnant women suffering with anemia

6. High risk neonates

(for preparedness at PHC & FRU)

7. Number of infants alive at 1 yr

(for immunization activities)

8. Number of children below 3 yr

(for requirement of Vit. A doses)

9. Number of children below 5 yr

(for requirement of DT doses)

3.4 BIRTH RATE AND GENERAL FERTILITY RATE

Exercise 4

The Birth Rate of state-‘X’ and state-‘Y’ are 22 and 33 respectively, for the year 2001.
Compute their approximate General Fertility Rates.

3.5 STATISTICAL CHARTS

Exercise 1

In a state of over 100 million people, a total of 10608 maternal deaths were reported in 2001.
Following table categorizes this mortality according to the cause of death.

Cause of Maternal Death Number

Abortion 1453

Toxemia of pregnancy 1337

Bleeding of pregnancy and puerperium 2673

Malposition of child 902

Puerperal sepsis 1220

Anemia 2079

Not classifiable symptoms 944

Total 10608

Make a statistical chart that suitably represents this data.

Exercise 6

In your district, child immunization coverage of 2000 and 2001 is given in the following
table:

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Practical Manual
Coverage in %

2000 2001

BCG 72 66

HBV3 42 53

OPV3 63 72

DPT3 55 67

Measles 51 64

Illustrate this information through a suitable statistical chart.

3.6 BASIC RISK ESTIMATES

Exercise 7

To study the strength of association between ‘heavy work during ante-natal period’ and
‘low birth weight of baby’, a cohort of 515 heavy worker ANCs was followed up. A duly
matched control cohort of 515 sedantary-moderate worker ANCs were also followed up.
Complete follow up till the measurement of birth weight could be done in 506 and 511
subjects of the study and control cohort respectively. Following results were obtained:

Baby’s birth weight: Baby’s birth weight: Total

below 2500 g 2500 g or more

Heavy worker ANCs a: b:

189 317 506

Sedantary-moderate c: d:
worker ANCs 95 416 511

Total 284 733 1017

Compute the following on the basis of above data:

]
a) Relative Risk

b) Attributable Risk of heavy work during ante-natal period

c) Population Attributable Risk

3.7 PROTECTIVE EFFICACY OF A VACCINE

Exercise 8

Suppose, following are the results of a field trial of an inhalation (aerosol-based) measles
vaccine:

Had measles during follow-up Total

Yes No

Vaccinated Group 42 558 600

Unvaccinated Group 128 272 400

a) Can the prevalence in vaccinated and unvaccinated groups be compared by a test of

significance? If yes, suggest a suitable test.
42 b) Calculate the Protective Efficacy of the vaccine.
 Epidemiological and
3.8 VALIDITY AND PREDICTIVE ACCURACY OF A Statistical Exercises
SCREENING PROCEDURE
Exercise 9

A group of health workers, after being duly trained, were asked to:

l give home visit to all cases of “fever in under 5 children” occurring in a community;
and

l report suspect measles cases.

Serum measles antibody titers were also done in all these fever cases to confirm the
diagnosis (4 fold or greater rise). Following results were obtained:

Health workers report on 4 Fold or greater rise in Total

Suspect Measles Serum Measles Antibody Titers

Positive Negative

Positive 26 18 44

Negative 2 114 116

Total 28 132 160

Considering that ‘4 fold or greater rise in Serum Measles Antibody Titers’ is the gold test
for the disease, furnish the following on the basis of above data:

a) Number of false positive and false negative cases of measles in health workers report.

b) 1) Sensitivity;

2)

3)

4)
Specificity;

Predictive value of a positive result;

Predictive value of a negative result;

] of the health workers’ screening of measles.

3.9 ABC-VED ANALYSIS FOR A MEDICINE STORE

Exercise 10

You visit a PHC and collect some inventory management data from the medicine
store.Following is the initial table of data collected by you:

Item No. VED category % of annual investment

1 D 1

2 E 0.5

3 D 2

4 E 0.5

5 V 16

6 D 0.5

7 E 4

8 D 1

9 E 3
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Practical Manual
Item No. VED category % of annual investment

10 D 0.5

11 E 19

12 D 1

13 E 0.5

14 D 2

15 E 0.5

16 D 0.5

17 V 0.5

18 D 1

19 D 0.5

20 D 1

21 D 0.5

22 E 0.5

23 V 22

24 D 0.5

25 D 0.5

26 D 2

27 E 0.5

28 D 1

29 D 15

30 E 2

Total 100

Subject above data to ABC-VED analysis and present your findings.

3.10 LET US SUM UP

In this unit we have tested our knowledge and skills in dealing with some RCH related
epidemiological and statistical situations. While doing so, we have covered some practical
aspects of AFP surveillance and community need assessment. We have also learnt how to
convert tabular data into statistical charts. Computation of basic risk estimates; protective
efficacy of a vaccine; and validity and predictive accuracy of a screening procedure has
also been covered. We have also performed ABC-VED analysis on medicine store data.

In the next unit we will cover the practical aspects of family and clinico-social case study
before going the final unit of practical manual that deals with the field visits.

3.11 ANSWERS TO THE EXERCISES*

*Some of the answers given here may not necessarily be the best possible answers to the
questions asked. They are to facilitate you. You may differ with them.

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Exercise 1 Epidemiological and
Statistical Exercises
a) 1) Stool specimen collection

2) Outbreak response immunization

3) Active case search in the community

b) 1) Within 14 days of the onset of paralysis

2) Two

3) 24 hours or more

4) 8-10 grams (roughly of the size of adult’s thumb)

5) The container need not be sterile

6) No preservative/transport media is used

Exercise 2

Confirmed polio cases Wild polio virus could be isolated = 2

Cases referred to Expert Group Cases with inadequate stool specimen AND
at national level for the review (having residual weakness or died or lost to
follow-up = 6

Polio Compatible AFP Referred to – Discarded by Expert Group = 3

Non-Polio AFP AFP – (Confirmed+Compatible Polio) = 127

Exercise 3

Sl. Expected RCH related Statistical relationship Probable

No. events in the area with available information number

1. Pregnancies Population of area × Birth 140.8 = 141

rate of district/state

2. Deliveries/live births Probable number of pregnancies 141

3. Ante-natal registration 110% of probable number of 155.1 = 155

(for requirement of ANC pregnancies = Probable number
visits, IFA & TT doses) of pregnancies × 1.1

4. High risk ante-natal cases 15% of ante-natal registration 23.25 = 23

(for preparedness at PHC & FRU) = Ante-natal registration × 0.15

5. Pregnant women suffering with 50% of ante-natal registration 77.5 = 78

anaemia = Ante-natal registration × 0.5

6. High risk neonates 10% of estimated births/deliveries = 14.1 = 14

(for preparedness at PHC & FRU) Estimated births/deliveries × 0.10

7. Number of infants alive at 1 yr Live births – estimated infant deaths 73

(for immunization activities)

8. Number of children below 3 yr 8% of the population of area = 512

(for requirement of Vit. A doses) Population of area × 0.08

9. Number of children below 5 yr 13% of the population of area = 832

(for requirement of DT doses) Population of area × 0.13

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Practical Manual Exercise 4

Basic considerations:

1) Birth Rate is (Live births in an area during a yr.) / (Midyear population in same area
and yr.)

2) GFR is (Live births in an area during a yr.) / (Midyr 15-44 female population in same
area and yr.)

OR- (Live births in an area during a yr.) / (approx. 22% of midyear population in same
area and yr.)

3) The denominator in GFR is 22% or (22/100) of the denominator used in BR. Therefore,
GFR is mathematically related to BR.

4) The approximate GFR will be: BR × (100/22)

In the present case it will be:

22 × (100/22) = 100 for state-‘X’

and

33 × (100/22) = 150 for state-‘Y’

Exercise 5

Step 1. Computation of proportionate share of each cause of death:

Case of Maternal Death Number Proportion

Abortion 1453 13.7

Toxaemia of pregnancy 1337 12.6

Bleeding of pregnancy and puerperium 2673 25.2

Malposition of child 902 8.5

Puerperal sepsis 1220 11.5

Anaemia 2079 19.6

Not classifiable symptoms 944 8.9

Total 10608 100

Step 2. Making a suitable chart to represent this data:

Maternal mortality in the state according to cause of death

Abortion
9% 14%

Toxaemia of pregnancy

19% Bleeding of pregnancy

13% and puerperium
Malposition of child

Puerperal sepsis

12%
Anaemia

24% Not classifiable

9% symptoms

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Exercise 6 Epidemiological and
Statistical Exercises
Suitable chart to illustrate this information:

Child immunization coverage in the district in 2000 and 2001

80
70
60
Coverage in %

50
2000
40
2001
30
20
10
0
BCG HBV3 OPV3 DPT3 Measles

Exercise 7

a) Relative Risk =

Incidence among exposed / Incidence among non-exposed =

(a/a+b) / (c/c+d) = (189/506) / (95/511) = 2.01

b) Attributable Risk =

(Incidence among exposed – Incidence among non-exposed/Incidence among

exposed) × 100 =

[(a/a+b) – (c/c+d)] / (a/a+b) = [(189/506) - (95/511)] / (189/506) = 0.5 or 50%

c) Population Attributable Risk =

(Incidence in population – Incidence among non-exposed)/Incidence in population =

[P – (c/c+d)] / P = [0.33 – (125/511)] / 0.33 = 0.3 or 30%

Exercise 8

a) Yes. They can be compared by ‘z’ test, using standard error of difference between two
proportions.

b) Protective Efficacy of a vaccine is calculated by the formula -

[(Prevalence in Unvaccinated – Prevalence in Vaccinated) / (Prevalence in

Unvaccinated)] × 100

In this data PE of the vaccine will be: [(32 – 7) / (32)] × 100 = 78.12

Exercise 9

a) False positive: 18; false negative: 2.

b) 1) Sensitivity = (True positive/Total disease positive) × 100 = (26/28) × 100 = 92.8

2) Specificity = (True negative/Total disease negative) × 100 = (114/132) × 100 = 86.4

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Practical Manual 3) Predictive value (+) = (True positive/Total test positive) × 100 = (26/44) × 100 = 59.1

4) Predictive value (–) = (True negative/Total test negative) × 100 = (114/116) × 100
= 98.3

Exercise 10

Step 1. Arranging the medicines in descending order of expenditure incurred.

Item No. VED category % of annual investment

23 V 22

11 E 19

5 V 16

29 D 15

7 E 4

9 E 3

3 D 2

14 D 2

26 D 2

30 E 2

1 D 1

8 D 1

12 D 1

18 D 1

20 D 1

28 D 1

2 E 0.5

4 E 0.5

6 D 0.5

10 D 0.5

13 E 0.5

15 E 0.5

16 D 0.5

17 V 0.5

19 D 0.5

21 D 0.5

22 E 0.5

24 D 0.5

25 D 0.5

27 E 0.5

Total 100
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Step 2. Do the ABC-VED analysis and present the results as follows: Epidemiological and
Statistical Exercises

Total % of % of annual
V E D
items items investment
A AV: AE: AD:
23, 5 11 29 4 13 72
B BV: BE: BD:
Nil 7, 9, 30 3, 14, 26 6 20 15

C CB: CE: CD:

17 2, 4, 13, 1, 6, 8, 10, 16, 18, 20 67 13
15, 22, 27 19,20,21,24,25,28

Total
items 3 10 17 30 100 100

* Numbers listed in boxes are item numbers.

Category I 5 (17%) items Most important

Category II 12 (40%) items Important

Category III 13 (43%) items Least important

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