PAPER

EPIDEMIOLOGI INTERMEDIET

DISUSUN OLEH :

1. AYU SUPRIASI 8. ROSINA KARDINA

2. ELAR GUMILAR 9. TITA ZHAFIRAH
3. FRANSISKA ANITA 10. YANDI FEBRITAMA
4. FITRIYA 11. YANG FAJAR KURNIAWAN
5. ERMILIA SARI 12. YULI ARDIANI
6. ALFIATUR RIZKI 13. SIFA FAUZIAH
7. HERI IRAWAN 14. TINA

UNIVERSITAS MUHAMMADIYAH PROF. DR. HAMKA JAKARTA

PROGRAM STUDI PASCA SARJANAILMU KESEHATAN

MASYARAKAT

TAHUN 2017
 Exercise 1. Relating risk factor to health
Background
Several well-designed and executed epidemiologic studies have implicated
enviroxide as a potential cause of environitis, newly recognized disorder in small
country called Carolina (pop. 10,000). In addition, a hitherto-unseen form
influenza, influenza J, has also been discovered and is believed to be associated
with exposure to bird as household pets. Although they are unrelated, the two
disorders have similar clinical pictures, with two-week acute phase for which the
most prominent symptom is a profound feeling “like being back in graduate
school’. Fortunately symptoms resolve quickly and completely, with apparent
immunity to further episode. Recent survey data indicates that 15% of the
population are exposed to high levels (100ppm) of enviroxide; 40% of the
population have a pet bird in the household. There is no association between this
two exposures.
Separate research teams conduct two-year cohort studies of these disorders. Thank
to Carolina’s very low mortality rate and restrictive emigration policies, there is
no loss to follow-up in either study. The first study recruits 1.000 persons living in
buildings with enviroxide levels>100ppm (“exposed”) and 1.000 persons living in
buildings with enviroxide levels<100ppm (“unexposed”); 700 exposed participant
develop environitis, as do 500 unexposed participants. In the second study 2.000
bird owners (“exposed”) and 2.000 persons who do have any contact with birds
(“unexposed”) are recruited; 400 exposed participants contract influenza J; 160
unexposed participants do also.

QUESTIONS AND ANSWERS

Part A. Measures of Association
1. Create a 2x2 table for each cohort study.

First Study
Environitis Not environitis Total
Exposed (People in building 700 300 1000
with enviroxide level > 100ppm
Unexposed 500 500 1000

Total 1200 800 2000

Second Study
Environitis Not environitis Total
Exposed 400 1600 2000
unexposed 160 1840 2000
Total 560 3440 4000
2. For each study calculate the following measures. For rate computations,
assume that case occurred uniformly during the follow-up period.
a. Incidence proportions (cumulative incidences, CI)
b. Incidence rates (incidence densities, ID)
c. Cumulative incidence ratio (CIR)
d. Incidence density ratios (IDR)
e. Odds ratio (OR)
f. Risk differences ( cumulative incidences differences, CID)
g. Incidence rate differences (incidences density differences, IDD)
Answer:

First Study
𝑘𝑎𝑠𝑢𝑠 𝑏𝑎𝑟𝑢
a. 𝐶𝐼 = 𝑝𝑜𝑝𝑢𝑙𝑎𝑠𝑖 𝑖𝑛𝑖𝑠𝑖𝑎𝑙
700 + 500 1200
𝐶𝐼 = = = 0,6
2000 2000
𝑘𝑎𝑠𝑢𝑠 𝑏𝑎𝑟𝑢
b. 𝐼𝐷 = 𝑜𝑟𝑔+𝑤𝑎𝑘𝑡𝑢

1200 1200
𝐼𝐷 = (1200𝑥1)+(800𝑥2) = = 0,43/y
2800

𝐶𝐼 𝑝𝑎𝑑𝑎 𝑒𝑥𝑝𝑜𝑠𝑒𝑑
c. 𝐶𝐼𝑅 = 𝐶𝐼 𝑝𝑎𝑑𝑎 𝑢𝑛𝑒𝑥𝑝𝑜𝑠𝑒𝑑
700
𝐶𝐼 𝑝𝑎𝑑𝑎 𝑒𝑛𝑣𝑖𝑟𝑜𝑥𝑖𝑑𝑒 = = 0,7
1000

500
𝐶𝐼 𝑝𝑎𝑑𝑎 𝑢𝑛𝑒𝑥𝑝𝑜𝑠𝑒𝑑 = = 0,5
1000
0,7
𝐶𝐼𝑅 = = 1,4
0,5
𝐼𝑅 𝑝𝑎𝑑𝑎 𝐸𝑛𝑣𝑖𝑟𝑜𝑥𝑖𝑑𝑒
d. 𝐼𝐷𝑅 =
𝐼𝑅 𝑝𝑎𝑑𝑎 𝑈𝑛𝑒𝑥𝑝𝑜𝑠𝑒𝑑
𝑗𝑙𝑚 𝑖𝑛𝑑𝑖𝑣𝑖𝑑𝑢 𝑦𝑔 𝑚𝑛𝑔𝑎𝑙𝑎𝑚𝑖 𝑝𝑒𝑟𝑖𝑠𝑡𝑖𝑤𝑎
𝐼𝑅 𝑝𝑎𝑑𝑎 𝑒𝑛𝑣𝑖𝑟𝑜𝑥𝑖𝑑𝑒 =
𝑗𝑙𝑚 𝑖𝑛𝑑𝑖𝑣𝑖𝑑𝑢 𝑏𝑒𝑟𝑒𝑠𝑖𝑘𝑜

700
𝐼𝑅 𝑝𝑎𝑑𝑎 𝑒𝑛𝑣𝑖𝑟𝑜𝑥𝑖𝑑𝑒 = = 0,538 = 0,54/𝑦
2000 − 700

500
𝐼𝑅 𝑝𝑎𝑑𝑎 𝑢𝑛𝑒𝑥𝑝𝑜𝑠𝑒𝑑 = = 0,333 = 0,33/𝑦
2000 − 500
0,54
𝐼𝐷𝑅 = = 1,63
0,33
 e. Odds Ratio/OR
700𝑥500 35
𝑂𝑅 = = = 2,33
300𝑥500 15

f. Risk Difference/Cumulative Insidences Difference/CID

𝐶𝐼𝐷 = 𝐶𝐼 𝑒𝑥𝑝𝑜𝑠𝑒𝑑 − 𝐶𝐼 𝑢𝑛𝑒𝑥𝑝𝑜𝑠𝑒𝑑
𝐶𝐼𝐷 = 0,7 − 0,5 = 0,20

g. Insiden Rate Difference/Incidences Density Difference/IDD

𝐼𝐷𝐷 = 𝐼𝑅𝑒𝑥𝑝𝑜𝑠𝑒𝑑 − 𝐼𝑅𝑢𝑛𝑒𝑥𝑝𝑜𝑠𝑒𝑑
𝐼𝐷𝐷 = 0,54 − 0,33 = 0,21/𝑦
Second Study
𝑘𝑎𝑠𝑢𝑠 𝑏𝑎𝑟𝑢
a. 𝐶𝐼 = 𝑝𝑜𝑝𝑢𝑙𝑎𝑠𝑖 𝑖𝑛𝑖𝑠𝑖𝑎𝑙
400 + 160 560
𝐶𝐼 = = = 0,14
4000 4000
𝑘𝑎𝑠𝑢𝑠 𝑏𝑎𝑟𝑢
b. 𝐼𝐷 = 𝑜𝑟𝑔+𝑤𝑎𝑘𝑡𝑢

560 560
𝐼𝐷 = (560𝑥1)+(3440𝑥2) = = 0,075/y
7440

𝐶𝐼 𝑝𝑎𝑑𝑎 𝑒𝑥𝑝𝑜𝑠𝑒𝑑
c. 𝐶𝐼𝑅 = 𝐶𝐼 𝑝𝑎𝑑𝑎 𝑢𝑛𝑒𝑥𝑝𝑜𝑠𝑒𝑑
400
𝐶𝐼 𝑝𝑎𝑑𝑎 𝑒𝑛𝑣𝑖𝑟𝑜𝑥𝑖𝑑𝑒 = = 0,2
2000

160
𝐶𝐼 𝑝𝑎𝑑𝑎 𝑢𝑛𝑒𝑥𝑝𝑜𝑠𝑒𝑑 = = 0,08
2000
0,2
𝐶𝐼𝑅 = = 2,5
0,08
𝐼𝑅 𝑝𝑎𝑑𝑎 𝐸𝑛𝑣𝑖𝑟𝑜𝑥𝑖𝑑𝑒
d. 𝐼𝐷𝑅 =
𝐼𝑅 𝑝𝑎𝑑𝑎 𝑈𝑛𝑒𝑥𝑝𝑜𝑠𝑒𝑑
𝑗𝑙𝑚 𝑖𝑛𝑑𝑖𝑣𝑖𝑑𝑢 𝑦𝑔 𝑚𝑛𝑔𝑎𝑙𝑎𝑚𝑖 𝑝𝑒𝑟𝑖𝑠𝑡𝑖𝑤𝑎
𝐼𝑅 𝑝𝑎𝑑𝑎 𝑒𝑛𝑣𝑖𝑟𝑜𝑥𝑖𝑑𝑒 =
𝑗𝑙𝑚 𝑖𝑛𝑑𝑖𝑣𝑖𝑑𝑢 𝑏𝑒𝑟𝑒𝑠𝑖𝑘𝑜

400
𝐼𝑅 𝑝𝑎𝑑𝑎 𝑒𝑛𝑣𝑖𝑟𝑜𝑥𝑖𝑑𝑒 = = 0,11/𝑦
4000 − 400
160
𝐼𝑅 𝑝𝑎𝑑𝑎 𝑢𝑛𝑒𝑥𝑝𝑜𝑠𝑒𝑑 = = 0,04/𝑦
4000 − 160
0,11
𝐼𝐷𝑅 = = 2,75
0,04
 e. Odds Ratio/OR
400𝑥1840 736
𝑂𝑅 = = = 2,87
160𝑥1600 256

f. Risk Difference/Cumulative Insidences Difference/CID

𝐶𝐼𝐷 = 𝐶𝐼 𝑒𝑥𝑝𝑜𝑠𝑒𝑑 − 𝐶𝐼 𝑢𝑛𝑒𝑥𝑝𝑜𝑠𝑒𝑑
𝐶𝐼𝐷 = 0,2 − 0,08 = 0,12

g. Insiden Rate Difference/Incidences Density Difference/IDD

𝐼𝐷𝐷 = 𝐼𝑅𝑒𝑥𝑝𝑜𝑠𝑒𝑑 − 𝐼𝑅𝑢𝑛𝑒𝑥𝑝𝑜𝑠𝑒𝑑
𝐼𝐷𝐷 = 0,11 − 0,04 = 0, 𝑜7/𝑦

3. Compare and contrast the ratio measures in each cohort, why do different
exist?

First Study (lingkungan dgn Second Study

enviroxide) (Pet bird)
CI 0,6 0,14
ID 0,43/y 0,075/y
CIR 1,4 2,5
IDR 1,63 2,75
OR 2,33 2,87
CID 0,20 0,12
IDD 0,21/y 0,07/y

Ada perbedaan hasil antara studi kohort pertama dan kedua, hal ini
disebabkan karena populasi dan sample yang digunakan pada kedua studi
berbeda baik dari sasaran maupun jumlah.

Part B. Measures of Impact–adverse exposure

1. For which associations do the data provide stronger evidence that the
association is causal?
Answer :
Kekuatan hubungan Asosiasi dapat dilihat dari nilai RR (CIR/IDR) dan
OR, dimana jika kita melihat tabel perbandingan pada Part A, jelas
terrlihat bahwa hubungan sebab-akibat yang paling kuat terdapat pada
exposure pet bird dengan kejadian environitis.

2. In preparation for the next election, the Carolina government is seeking

public health success. Assuming the resources and intervention expertise
are available to eliminate either enviroxide or pet birds, but not both,
which of these two exposures should be chosen for the prevention program
 in order to have the most visible result? What epidemiologic measure(s)
can assist you in this decision?
Answer :
Ukuran Epidemiologi yang dapat membantu dalam membuat keputusan
adalah dengan terlebih dahulu menghitung nilai Risk
Difference/Atributtable Risk dari masing-masing populasi untuk
mengetahui dampak dari masing-masing exposure. Dengan demikian akan
lebih mudah dalam membuat keputusan yang tepat.

First Study
Exposed (People in building with Unexposed Total
enviroxide level > 100ppm
Jlm individu 15% x 10.000 = 1500 8500 10000
yg beresiko
CI 0,7 0,5

Total Case 0,7 x 1500 = 1050 4250 5300

PAR = CID x P1 = 0,20 x 15% = 0,03

Jumlah kasus yg dpt dicegah = 0,03 x 10.000 = 300 kasus
𝑃(𝐶𝐼𝑅 − 1) 15%(1,4 − 1) 0,06
𝑃𝐴𝑅% = 𝑥100% = 𝑥100% = 𝑥100%
1 + 𝑃(𝐶𝐼𝑅 − 1) 1 + 15%(1,4 − 1) 1,06
= 0,056 𝑥 100% = 5,66 %
Second Study

Exposed (Pet Bird) Unexposed Total

Jlm individu 40% x 10.000 = 4000 6000 10000
yg beresiko
CI 0,20 0,08

Total Case 0,20 x 4000 = 800 480 1280

PAR = CID x P1 = 0,12 x 40% = 0,048

Jumlah kasus yg dpt dicegah = 0,048 x 10.000 = 480 kasus
𝑃(𝐶𝐼𝑅 − 1) 40%(2,5 − 1) 0,6
𝑃𝐴𝑅% = 𝑥100% = 𝑥100% = 𝑥100%
1 + 𝑃(𝐶𝐼𝑅 − 1) 1 + 40%(2,5 − 1) 1,6
= 0,375 𝑥 100% = 37,5%
Part C. Measures of impact–preventive exposure
Eliminating pet bird ownership will not be popular, however. Seeking a
biomedical solution, the government launches a crash program to develop a
vaccine. In the subsequent double-blind, randomized efficacy trial of candidate
vaccine, among 162 persons receiving the vaccine 9 subsequently develop
influenza J; of the 169 receiving placebo, 24 contract influenza J.
1. What is the efficacy of the new vaccine? (i.e. in what percent of the study
group was disease prevented?)
Answer :
9
Vaccine : 𝐶𝐼1 = 162 = 0,056
24
Placebo : 𝐶𝐼2 = 169 = 0,142
Prevented Fraction/PF
0,142 − 0,056
𝑃𝐹 = = 0,606 = 61%
0,142

2. Focus groups suggest that only 30% population will accept the vaccine,
however. If this projection is correct, what will the population
effectiveness of the vaccine be?
Answer :
PF = 30% x 0,606 = 18,2 %

3. Given the low effectiveness due the behavioral aspect of vaccine

administration, Carolina public health strategist opt instead for
environmental modification and preventing environitis. They propose a
crash enviroxide abatement program to completely eliminate enviroxide
exposure. What proportion of environitis case will be prevented?
a. In persons living in buildings with enviroxide?
Answer :
𝐼𝑒𝑥𝑝𝑜𝑠𝑒𝑑−𝐼𝑢𝑛𝑒𝑥𝑝𝑜𝑠𝑒𝑑 0,7−0,5
𝐴𝑅% = 𝑥 100% = 0,7 x100% = 28,57%
𝐼𝑒𝑥𝑝𝑜𝑠𝑒𝑑

b. In the population:
Answer :
𝑃(𝐶𝐼𝑅 − 1) 15%(1,4 − 1)
𝑃𝐴𝑅% = 𝑥100% = 𝑥100%
1 + 𝑃(𝐶𝐼𝑅 − 1) 1 + 15%(1,4 − 1)
0,06
= 𝑥100% = 0,056 𝑥 100% = 5,66 %
1,06