PROBLEMS

EPIDEMIOLOGICAL STUDY

1. In a case control study 640 subjects were enrolled to find out the association of blindness with
diabetes the following were the results obtained. Among 300 diabetics, 180 had blindness. The
total number of subjects with blindness was 320. Calculate the exposure rates among the cases
and controls, Odd’s Ratio and comment on the same.

Solution:
Framework of data: 2 marks

Blindness Present Blindness Absent TOTAL

Diabetes Present 180 (a) 120 (b) 300

Diabetes Absent 140 (c) 200 (d) 340
TOTAL 320 (a + c) 320 (b + d) 640

𝑎 180
1. Exposure rate among the cases = × 100 = 320 × 100 = 56.25% 2 marks
𝑎+𝑐

𝑏 120
2. Exposure rate among the control= 𝑏+𝑑 × 100 = 320 × 100 = 37.5% 2 marks

Odds ratio (OR)

Odds of exposure among cases 𝑎𝑑 180×200

= = = 2.14 2 marks
Odds of exposure among controls 𝑏𝑐 120×140

Inference: 2 marks
Exposure rate among cases = 56.3%
Exposure rate among controls =37.5%
Odds ratio =2.14
Diabetics are at 2.14 times more risk of developing blindness than the non – diabetics.

2. A cohort study was conducted to study the association between smoking and lung cancer. It was
found that among the 10,000 subjects who were enrolled for the study, 7000 of them were
smokers. Among those who developed lung cancer, 70 were smokers and 3 were non smokers.
Calculate and interpret the following:
 Incidence rate of lung cancer among smokers and non smokers
 Relative risk
 Attributable risk
Given data
 Total number of subjects enrolled for the study = 10000
 Total number of subjects who were smokers = 7000
 Total number of subjects who developed lung cancer =73
 Number of smokers who developed lung cancer =70

Solution
Frame work of data 2 marks
Lung cancer present Lung cancer absent Total

Smokers 70(a) 6930 (b) 7000 (a+b)

Non smokers 3(c) 2997 (d) 3000(c+d)
Total 73 (a+c) 9927 (b+d) 10000

Incidence rates of lung cancer among smokers and non smokers

𝑎 70
I E = Incidence of lung cancer among the smokers = X1000 = 7000 X1000 2 marks
𝑎+𝑏

= 10/1000 smokers
𝑐 3
INE = Incidence of lung cancer among the non smokers= 𝑐+𝑑 X1000= 3000 X1000 2 marks

= 1 / 1000 nonsmokers

Relative Risk (RR) 1 marks

Incidence of lung cancer among the smokers IE 𝑎/(𝑎+𝑏) 70 / 7000
= =
Incidence of lung cancer among the non smokers INE 𝑐 /(𝑐+𝑑) 3 / 3000

0.01
= = 10
0.001

𝐼𝐸 – 𝐼𝑁𝐸 0.01– 0.001

Attributable Risk = X 100 = X 100 = 90% 1 marks
𝐼𝐸 0.01

Inference 2 marks

 Incidence of lung cancer among the smokers = 10/ 1000 smokers

 Incidence of lung cancer among the non smokers = 1/ 1000 non smokers

Relative Risk = 10

Smokers are 10 times at more risk of developing lung cancer as compared to those who are non
smokers
 Attributable Risk = 90%

Attributable risk indicates to what extent the disease under study can be attributed to the
exposure. Thus attributable risk of 90% means 90% of the lung cancer among smokers
was attributed to their smoking.

3. 15 cases of suspected cholera have been reported in a village of 4500 population with 2 Bore
wells and one public well as main sources of drinking water supply. As a medical officer of a
PHC, how will you manage such an outbreak.

Solution:
 Medical Officer with his epidemic team should immediately visit that village. Epidemic clinic
is started and kept open 24hrs in that village.
 Start oral rehydration therapy immediately for all the affected people.
 Collect stool samples in sterilized Mc. Cartney bottles containing [Link] and send it to
the lab.
 Give tetracycline- 500mg B.D for 3 days or doxycycline 300mg single dose to the patients,
house members and neighbours.
 Notifying the DHO.
 Patient’s stool, vomits, clothes, personal items, latrine etc, should be disinfected.
 Get a list of all those affected, their family members and neighbours. Educate people on
hygiene and to wash hands with soap and water before meals and after defecation.
 Fly control measures should be undertaken like covering the food, using fly papers,
maintaining sanitation that is not throwing garbage indiscriminately.
 Chlorinate the source of water. Distribute halogen tablets.
 Improve sanitary system. Advice people to construct and use bore/pit latrines with water seal
or septic tanks or aqua privy.
 Educate on food sanitation storage and handling techniques. Ban street vendors from selling
cut fruits and other exposed food stuffs.
 Epidemic kits containing sufficient quantities of IV fluids (RL, DNS etc) ORS packets,
antibiotics etc should be kept ready at PHC level.
 Epidemic team consisting of M.O, health assistants, attendants, should be available round the
clock at PHC.

4. A single case of Acute flaccid paralysis (AFP) is reported in a 4 year old boy from Village X of
Kanakapura taluk, Karnataka.
I. How will you investigate the case.
II. Describe the strategies for Polio Eradication .
Solution:
Even a single case of AFP is treated as an outbreak and the following investigation is initiated usually
within 48 hrs of the notification of the case (Containment measures are not recommended if the period
after the onset of paralysis is more than 14 days).
I) Case Investigation :
 AFP case notification: The reporting units (RUs) and AFP informers notify AFP cases to the
RCHO/ SMO. Acute flaccid paralysis is defined as sudden onset of weakness and floppiness in
any part of the body in a child < 15 years of age or paralysis in a person of any age in whom polio
is suspected.
 AFP case investigation: An AFP case is immediately investigated usually within 48hrs of
notification by RCHO / SMO. The RCHO/SMO will, take relevant history, clinically examine the
child and fill a standard case investigation form.
 Stool specimen collection and transportation: From every case of AFP, 2 stool specimens are
collected with in 14 days of onset of paralysis and atleast 24 hrs apart.
 Outbreak response immunization : Outbreak response immunization i.e ring immunization is
organized in the community . All 0 to 59 months(0-5 yrs) old children are given 1 dose of bOPV .
Atleast 500 children are vaccinated.
 Active case search in the community: In the community where AFP case lives a house to house
active case search is organized to find and rule out more AFP cases.
 60 days follow up examination: The RCHO /SMO revisits every case of AFP 60 days after the
onset of paralysis to confirm the presence or absence of residual weakness.
 Case classification: The cases are classified at NPSU as polio or non polio.
 A case is classified as polio if wild polio virus(WPV) is isolated from the stool samples.
 A case is classified as non polio if two adequate stool samples (within 14 days) are collected and
negative for WPV isolation. Cases with inadequate stool specimen and having residual
weakness/died or lost to follow up- are subjected to special investigation and reviewed by the
expert group at National level. The expert group classifies the case as compatible or discarded

II) Strategies for polio eradication :

The following are the strategies followed in the Polio eradication campaign.
a. Routine immunization (RI): Sustaining high levels of coverage with 3 doses of bOPV in the 0-1
year age group.
b. Supplementary Immunization Activities(SIA): Simultaneous administration of bOPV to all
children in the age group of 0-5 years, 4 to 6 weeks apart to interrupt WPV transmission and to
increase immunity among children.
SIAs include:
▪ National Immunization Days ( NIDs) when the entire country is covered.
▪ Sub National Immunization Days (SNIDs) when some states or parts of some states are covered.
▪ Mop-ups are conducted, as soon as possible after identification of the virus as an end game strategy
to interrupt transmission ,when virus transmission is focalized and polio cases are found in specific
areas.
 c. Surveillance of Acute Flaccid Paralysis (Surveillance data is used to identify areas of WPV
transmission and to guide immunization activities) is as follows :
i) Establishment and maintenance of reporting units (RUs): reporting units form the backbone of
surveillance network. The RUs send the weekly AFP surveillance report to Dist. RCHO and
SMO,WHO-NPSP. ii). Cross notification and tracking of cases iii). Data management analysis &
Feedback.

5. An Intern had a needle stick injury while suturing a lacerated wound in the casualty. How
would you manage this injury?

Solution
Post exposure prophylaxis is recommended whenever the patient is known HIV positive / status is not
known/ suspect HIV or Hepatitis B positive/ Status is not known/ Suspect Hepatitis B.
The following are the steps of Post Exposure Prophylaxis (PEP)
1. Immediately following an exposure, the hands should be washed thoroughly with soap and running
water. Do not put pressure on the wound to stop bleeding. Do not put the finger in the mouth
reflexly.
2. Squeeze the wound to let out blood and clean with antiseptic agent.
3. Enter the injury details in the injury register which is kept in the casualty.
4. Inform this incident to the head of the hospital.
 To prevent Hepatitis B the following action should be taken:
 Passive immunization with Hepatitis B Immunoglobulin – 0.05 to 0.07 ml /kg body wt of pooled
human origin. It has to be injected intramuscularly. Two doses of immunoglobulin should be
given thirty days apart. The first dose should be given as early as possible. The immunoglobulin
provides protection for three months.
 Active Immunisation – Recombinant DNA vaccine is used. Adult dose at 0, 1, 6 months given in
the deltoid area. For new born and children half the adult dose is given.
 To prevent HIV infection the following action should be taken:
 The first dose of PEP should be administered ideally within 2 hours (but preferably within the
first 72 hours) of exposure and the risk evaluated as soon as possible. The following drugs are
available for PEP: Tenofovir (300 mg) + Lamivudine (300 mg) + Dolutegravir (50 mg) (FDC:
One tablet OD), Duration of PEP is 28 days.
 These drugs are available free of cost at all Government Hospitals through the AIDS Control
Societies and also in ICTC Centres.
 All needle stick injuries should be reported to State AIDS Control Societies giving the exposure
code and HIV status code. The State AIDS Control Societies should inform the NACO about this
periodically.

6. A Primary School Teacher with a small family consisting of wife and an infant was presumed
to have pulmonary TB. How do you confirm the diagnosis? Outline the steps to be taken in the
management of the case, contacts and community.
 Solution:
1. Confirmation of diagnosis:
a. History
b. Sputum examination –
i. Direct microscopy
ii. CBNAAT/ TRUNAAT
iii. Line probe assay
iv. Culture (solid and liquid) which is gold standard
2. Management:
1. Case
a. Treatment
i. Chemotherapy- short course of chemotherapy
ii. Hospitalization if necessary
b. Preventive measures
i. Disinfect sputum by burning/ 5% cresol.
ii. Rehabilitation.
iii. Health education:
-complete treatment.
-disinfect sputum
-avoid contacts.
-follow-up
2. Contacts
i. school children
ii. family members
a. Screening of all household contacts for TB (IGRA) and initiation of TB preventive therapy
(INH)
b. If sputum is positive – treatment
c. If sputum negative – infant BCG, avoid contact with case.
d. Health education.
3. Community.
a. Case finding (active/passive) and treatment of cases.
b. BCG vaccination.
c. Health education
-cough etiquette
-nutrition

7. High incidence of Hookworm infestation is reported from a village. Outline the procedures you
would adapt to control and prevent this.

Solution:
A. Control of patient, contacts and the immediate environment:
Specific treatment:
 1) Single dose oral treatment with mebendazole, albendazole (half dose for children 12–24 months),
levamisole or pyrantel pamoate is recommended; adverse reactions are infrequent. Follow-up stool
examination is indicated after 2 weeks, and treatment must be repeated if a heavy worm burden
persists.
2) Iron supplementation will correct the anemia and should be used in conjunction with deworming.
Pregnant women should not be treated in the first trimester unless there are specific medical or
public health reasons.
3) Concurrent disinfection: Safe disposal of faeces to prevent contamination of soil.
4) Investigate contacts and source of infection: Each infected contact and carrier is a potential or actual
indirect spreader of infection.

B. Preventive measures:
1) Educate the public to the dangers of soil contamination by human, cat or dog feces, and in
preventive measures, including wearing shoes in endemic areas.
2) Prevent soil contamination by installation of sanitary disposal systems for human feces, especially
sanitary latrines in rural areas. Night soil and sewage effluents are hazardous, especially where used
as fertilizer.
3) Examine and treat people migrating from endemic to receptive nonendemic areas, especially those
who work barefoot in mines, construct dams or work in the agricultural sector.
4) WHO recommends a strategy focused on high-risk groups for the control of morbidity due to soil-
transmitted helminths, including community treatment differentiated according to prevalence and
severity of infections:
i) Universal medication of women (once a year, including pregnant women) and preschool children
over 1 year (twice or thrice a year) if schoolchildren show 10% or more of heavy infections (4000+
hookworm eggs per gram of faeces) whatever the prevalence;
ii) Yearly community medication targeted to risk groups (including pregnant women) if prevalence
>50% and schoolchildren show <10% of heavy infections;
iii) Individual case management if prevalence <50% and schoolchildren show <10% of heavy
infections. Extensive monitoring has shown no significant ill effects of administration to pregnant
women under these circumstances
C. Epidemic measures:
Prevalence survey in highly endemic areas: provide periodic mass treatment. Health education in
environmental sanitation and personal hygiene, and provide facilities for excreta disposal.

8. XYZ is a 2 year old who is brought to your centre with a complaint of diarrhea and fever for the
last 2 days. On examination XYZ is found to be irritable. His lips and tongue are dry and when
he cries there are no tears. When offered a drink he takes it eagerly and cries for more. His skin
pinch goes back quickly.
a) What kind of dehydration does XYZ have?
b) Which plan of treatment will you follow? Briefly explain the steps of treatment according to
this plan?
c) What advice will you give to prevent such attacks in the future?
 Solution
a. Restless, irritable, drinks eagerly, skin pinch goes back quickly, dry eyes, no tears and dry tongue –
all these symptoms point towards a diagnosis of some dehydration. So, he has ‘Some dehydration’.
b. For ‘some dehydration’ treatment plan B should be followed. XYZ weighs 10kgs i.e. 84% of the
expected weight for age. Weight = 2x +8 = 2(2) + 8 = 12 kgs; 84% of 12 kgs = 10 kgs.
ORS is given in the quantity of 75 ml /kg body weight i.e. 10 kg x 75 ml = 750 ml. Educate mother as
to how to prepare ORS: give 1 tea spoon 1 – 2 minute over 4 hrs.
Check from time to time for any worsening of conditions. If the child vomits, wait for 10 minutes and
then continue ORS and plain water.
Re-assess the child according to symptoms and treat according to plan A, B, or C.
c. XYZ improves and his mother is ready to take him home. The following are the important
recommendations to prevent such attacks in future:
• Educate the mother about proper food sanitation which includes: Food hygiene, proper hand washing
practices (after defecation, before cooking and feeding food), adequate cooking of food and keeping
the food covered always.
• Also educate her about defecation to be done only in a latrine and not to practice open air defecation;
if there is no latrine, defecate at least 10 m away from a water source.
• Immunization to be completed as per the schedule and fly control to be done.

9. A few cases of Fever and Fever with Bleeding from gums and nose (KFD Cases) were reported
to Shimoga Primary Health Centre. Villagers have also reported that they have seen few dead
monkeys in adjoining forest and outskirts of villages. Discuss step wise how you would manage
this problem if you were the Medical Officer of the Shimoga Primary Health Centre

Solution
The above history and clinical features point towards a diagnosis of “Kyasanur forest disease” . This
disease is endemic in Shimoga district.
The management of this problem can be done in this manner.
Step 1: Case management
1. Go to the primary health centre and confirm the existence of the disease. The confirmation can
be done by the following
2. Detailed history
3. Clinical examination
4. Serological evidence of presence of virus in the blood
5. Symptomatic management of the cases by giving antipyretics, analgesics and managing
bleeding manifestations
6. Look out for the signs of meningo-encephalitis (complications)

Step 2: Community action

1. Rapid search for the cases
 A map of the area must be at hand before taking any action. This will help in dividing the
whole area into multiple smaller segments. This will help in conducting the survey and to
cover up the whole population. It will also help in identifying the ‘hot spots’
  Population ‘at risk’ must be identified. (The population which is at risk to get the infection)
 The CMO along with health workers in Shimoga district should carry out a medical survey to
identify the cases.
 We will have to develop questionnaires to enquire about the visits by the villagers to the forests
where dead monkeys have been seen and also about the clinical features.
 Thus, ‘hot spots’ can be identified. These hot spots are those areas where monkey deaths have
been reported and 50 meters around the spot of death besides the endemic foci.

2. Control measures
KFD is a vector borne disease transmitted by the bite of infective ticks. And hence, to control the
spread of KFD we need to control ticks
 Spraying is an effective method to control ticks. Application can be done by power equipment
or aircraft mounted equipment.
 The insecticides used are Carbaryl, Fenthion, Naled or Propoxur at 2.24 kg of active ingredient
per hectare.
 Restriction of cattle movement: The tick population is attributed to the free roaming cattle in
the forest. Hence, restriction of cattle movement is a very important step to reduce vector
population. However, for this we need co-operation from forest officials and villagers.
 Vaccination: The population ‘at risk’ should be vaccinated with a dose of killed KFD vaccine.
 Personal Protection: can be done by adequate clothing, application of insect repellants (e.g.
Dimethylphthalate ), avoidance of sitting or lying down on the ground should be discouraged.

3. Health education
 Educating the people about the dynamics of transmission of KFD and the clinical features is
very important in early diagnosis of the condition and preventing similar conditions in future.
 Educating them to examine their clothes and bodies at the end of each day for ticks and remove
them promptly.

10. 39 cases of infective hepatitis with 2 deaths have occurred in a village of 8,000 population.
How will you investigate and contain the epidemic?

Solution:
1. Preparation for investigation by collecting various materials required for sample collection,
data collection, intimation to the higher authorities, collection of the area map, information
about the water sources, and constitution of the team for investigation.
2. Confirmation of the diagnosis by detailed clinical examinations, detection of viral antigens in
blood and stool samples.
3. Active search for the cases for early detection, search for primary & index cases.
4. Environmental measures: find the source of drinking water of that area, supply of milk,
collection of water samples to evaluate the possible sewage contamination.
5. Describing the outbreak in terms of place, person and time and plotting a graph or bar diagrams
 6. Tackling the situation, whether it is possible to cope with the existing resources or additional
resources in terms of manpower, material and money are required. Keeping in touch with
higher officials daily.
7. Control of Outbreak:
 Isolation of cases and immediate contacts.
 Case management with adequate rest, high glucose diet, supportive therapy, with
vitamins disinfection and proper disposal of excreta.
 Improvement of personal and community hygiene- Hand washing before eating and
after toilet, Sanitary disposal of excreta, Purification of water
8. To control transmission:
 Proper disposal of garbage & disinfection
 Supply of safe water with super-chlorination.
 Discouraging road side food and food from eating establishments
Agent: hepatitis A virus
Mode of transmission: Faeco-oral route

Communicable period: 2 weeks before appearance of prodromal symptoms to 1 week after appearance
of icterus.

1. Control of reservoir of infections: this step is difficult because

a. Fecal shedding of virus is highest during incubation period (15-45 days)
b. Large number of subclinical cases exist
c. Low SES of population involved. Therefore the measures should be
i. Notification of the cases to higher authorities
ii. Complete bed rest to the patients
iii. Disinfection of feces and fomites by 0.5% hypochlorite solution
2. Control of transmission of infection:
a. Prompt personal hygiene measures
b. Sanitary disposal of excreta which prevents contamination of water, food and milk
c. Chlorination of water done after initial steps like flocculation and filtration
d. Use of boiled and cooled drinking water during epidemic period
.
3. Control of susceptible population
a. Susceptible contacts & travelers to the endemic area. If a case has occurred in an institution,
the inmates of the institution.
b. Normal pooled human Ig given before exposure to the virus or in early incubation period may
prevent or attenuate the clinical illness. The duration of protection with dosage of 0.02 ml/ kg
body weight is 1-2 months and with 0.06ml/kg is 3-5 months. This protects 80-90% of the
exposed population when given within 14days after exposure
c. Vaccines: Inactivated vaccines are available at present which can be given in two doses, 6-8
months apart. Contraindicated in infants. Combination of HAV & HBV contains killed HAV &
 recombinant HBV. It is given in 3 doses at 0, 1 and 6th months. This is also given to those
aged > 1 year and not to infants.
4. Investigations
a. Serum bile pigments
b. Liver enzyme levels in the blood
c. Liver Function tests
d. Serum IgM
e. Stool examination for HAV virus and IgA antibody.

VITAL STATISTICS

Exercise 1:
A Community Health Centre recorded the following data in its service area in the year 2019.
Live births : 2000
Stillbirths : 25
Deaths within 7 days of birth : 50
th th
Deaths from 8 day to 28 day of birth : 70
th
Deaths from 29 day to one year of birth : 40
Maternal death : 4
Calculate the following rates for the year:
A) Stillbirth Rate
Ans. Stillbirth Rate = No. of stillbirths in one year x 1000
No. of total births (stillbirths + live births) in one year
= _ 25___ x 1000
25 + 2000
= _25 _ x 1000 = 12.3
2025
Stillbirth Rate = 12 per 1000 total births
B) Peri- Natal Mortality Rate (PMR)
Ans. Peri Natal Mortality Rate = No. of stillbirths + deaths within 7days of birth x 1000
No. of total births (stillbirths + live births) in one year
= _ 25 + 50_ x 1000
25 + 2000
= _75_ x 1000
2025
Peri Natal Mortality Rate = 37 per 1000 total births
C) Neo-natal Mortality Rate (NMR)
Ans. Neo-natal Mortality Rate (NMR) = No. of deaths within 28 days of birth in a year x 1000
No. of live births in a year
= _ 50 + 70_ x 1000 = 120 x 1000
2000 2000
Neo-natal Mortality Rate = 60 per 1000 live births
D) Post Neo-natal Mortality Rate (PNMR)
Ans. Post Neo-natal Mortality Rate = No. of deaths from 29th day to 1 year of birth x 1000
No. of live births in one year
= _ 40_ x 1000
2000
Post Neo-natal Mortality Rate = 20 per 1000 live births
E) Infant Mortality Rate (IMR)
Ans. Infant Mortality Rate = No. of infant deaths within one year of birth x 1000
No. of live births in one year
= _50 + 70 + 40_ x 1000
2000
= _160 _ x 1000
2000
Infant Mortality Rate = 80 per 1000 live births
F) Maternal Mortality Ratio (MMR)
Ans. Maternal Mortality Ratio = No. of maternal deaths in one year x 1000
No. of live births in one year
= _4 _ x 1000
2000
Maternal Mortality Ratio = 2 per 1000 live births
-------------------------------------------------------------------------------------------------------------

Exercise 2:
The service area of a PHC recorded the following data, in a particular year.
Mid year population (MYP) : 30000
Live births : 600
Deaths within 28 days of birth : 30
Deaths from 29th day to one year of birth : 6
Maternal deaths : 1
Calculate the following rates for the year:

A) Crude Birth Rate (CBR)

Ans. Crude Birth Rate = No. of live births in one year x 1000
Mid Year Population
= _ 600__ x 1000
30000
Crude Birth Rate = 20 per 1000 MYP

B) Neo-natal Mortality Rate (NMR)

Ans. Neo-natal Mortality Rate (NMR) = No. of deaths within 28 days of birth in a year x 1000
No. of live births in a year
= _ 30_ x 1000
600
Neo-natal Mortality Rate = 50 per 1000 live births
C) Post Neo-natal Mortality Rate (PNMR)
Ans. Post Neo-natal Mortality Rate = No. of deaths from 29th day to 1 year of birth x 1000
No. of live births in one year
= _ 6_ x 1000
600
Post Neo-natal Mortality Rate = 10 per 1000 live births

D) Infant Mortality Rate (IMR)

Ans. Infant Mortality Rate = No. of infant deaths within one year of birth x 1000
No. of live births in one year
= _30 +6_ x 1000
600
= _36 _ x 1000
600
Infant Mortality Rate = 60 per 1000 live births

E) Maternal Mortality Ratio (MMR)

Ans. Maternal Mortality Ratio = No. of maternal deaths in one year x 1000
No. of live births in one year
= _1 _ x 1000
600
Maternal Mortality Ratio = 1.66 per 1000 live births

-------------------------------------------------------------------------------------------------------------

Exercise 3:
A town in Andhra Pradesh state has recorded the following data in a particular year.
Mid year population (MYP) : 80000
Live births : 2000
Deaths within 28 days of birth : 120
Deaths from 29th day to one year of birth : 40
Maternal deaths : 4
Calculate the following rates for the year:

A) Crude Birth Rate (CBR)

Ans. Crude Birth Rate = No. of live births in one year x 1000
Mid Year Population
= _ 2000_ x 1000
80000
Crude Birth Rate = 25 per 1000 MYP

B) Neo-natal Mortality Rate (NMR)

Ans. Neo-natal Mortality Rate (NMR) = No. of deaths within 28 days of birth in a year x 1000
No. of live births in a year
= _120_ x 1000
2000
Neo-natal Mortality Rate = 60 per 1000 live births

C) Post Neo-natal Mortality Rate (PNMR)

Ans. Post Neo-natal Mortality Rate = No. of deaths from 29th day to 1 year of birth x 1000
No. of live births in one year
= _ 40_ x 1000
2000
Post Neo-natal Mortality Rate = 20 per 1000 live births

D) Infant Mortality Rate (IMR)

Ans. Infant Mortality Rate = No. of infant deaths within one year of birth x 1000
No. of live births in one year
= _120 + 40_ x 1000
2000
= _160 x 1000
2000
Infant Mortality Rate = 80 per 1000 live births

E) Maternal Mortality Ratio (MMR)

Ans. Maternal Mortality Ratio = No. of maternal deaths in one year x 1000
No. of live births in one year
= _4 _ x 1000
2000
Maternal Mortality Ratio = 2 per 1000 live births

-------------------------------------------------------------------------------------------------------------

Exercise 4:
The service area of a Community Health Centre (CHC) has recorded the following data, in
aparticular year.
Mid-year population (MYP) : 100,000
Live births : 2,400
Total deaths : 1,100
Deaths within one year of birth : 144
Maternal deaths : 3
Calculate the following rates for the year:

A) Crude Birth Rate (CBR)

Ans. Crude Birth Rate = No. of live births in one year x 1000
 Mid Year Population
= _2400_ x 1000
100000
= 24
Crude Birth Rate (CBR) = 24 per 1000 MYP

B) Crude Death Rate (CDR)

Ans. Crude Death Rate = No. of deaths in one year x 1000
Mid Year Population
= _1100_ x 1000
100000
= 11
Crude Death Rate (CDR) = 11 per 1000 MYP

C) Growth rate
Ans. Growth Rate = Crude Birth Rate – Crude Death Rate
= _24_ – 11_
1000 1000
= 24 –11
1000
= 13_
1000
Growth Rate = 13 per 1000 MYP (or) 1.3 %

D) Infant Mortality Rate (IMR)

Ans. Infant Mortality Rate = No. of infant deaths within one year of birth x 1000
No. of live births in one year
= _144 _ x 1000
2400
Infant Mortality Rate = 60 per 1000 live births

E) Maternal Mortality Ratio (MMR)

Ans. Maternal Mortality Ratio = No. of maternal deaths in one year x 1000
No. of live births in one year
= _3 _ x 1000
2400
Maternal Mortality Ratio = 1.25 per 1000 live births
-------------------------------------------------------------------------------------------------------------

Exercise 5:
The service area of a PHC has recorded the following data, during a particular year.
Mid year population (MYP) : 30000
Total number of males : 15464
 Total number of live births : 630
Total number of deaths : 270
Total No. of deaths among females : 150
Calculate the following:
A) Sex Ratio (Male Female Ratio) (1000: 940)
Ans. Sex Ratio (Male Female Ratio): means the number of females per 1000 males.
For this, first we should find out the no. of females in the total population.
No. of females = Total population – No. of males
= 30000 – 15464
= 14536
Sex Ratio (Male Female Ratio) = 15464: 14536
For 15464 males, there are = 14536 females
For 1000 males, there are =? females
= _14536 x 1000
15464
= 939.98
= 940
= 940 females per 1000 males
Sex Ratio = 1000: 940
B) Specific Mortality Rate for females
Ans. Specific Mortality Rate for females = No. of deaths of females in one year x 1000
Mid Year Population of females
= _150_ x 1000
14536
= 10.3
Specific Mortality Rate for old people = 10.3 per 1000 MYP of females
C) Crude Birth Rate (CBR)
Ans. Crude Birth Rate = No. of live births in one year x 1000
Mid Year Population
= _630_ x 1000
30000
= 21
Crude Birth Rate (CBR) = 21 per 1000 MYP
D) Crude Death Rate (CDR)
Ans. Crude Death Rate = No. of deaths in one year x 1000
Mid Year Population
= _270_ x 1000
30000
=9
Crude Death Rate (CDR) = 9 per 1000 MYP
E) Growth rate
Ans. Growth Rate = Crude Birth Rate – Crude Death Rate
= _21_ – 9_
 1000 1000
= 21 – 9
1000
= 12_
1000
Growth Rate = 12 per 1000 MYP (or) 1.2 %
-------------------------------------------------------------------------------------------------------------

Exercise 6:
During the previous year, a city has recorded the following data, which are given below:
Mid- year population (MYP) : 300,000
MYP of old people (60 years & above) : 20000
Total number of Live births in the year : 9000
Total number of deaths in the year : 4200
No. of deaths of old people (60 yrs & above): 1400
Calculate the following for the year:

A) Crude Birth Rate (CBR)

Ans. Crude Birth Rate = No. of live births in one year x 1000
Mid Year Population
= _9000_ x 1000
300000
= 30
Crude Birth Rate (CBR) = 30 per 1000 MYP

B) Crude Death Rate (CDR)

Ans. Crude Death Rate = No. of deaths in one year x 1000
Mid Year Population
= _4200_ x 1000
300000
= 14
Crude Death Rate (CDR) = 14 per 1000 MYP

C) Growth rate
Ans. Growth Rate = Crude Birth Rate – Crude Death Rate
= _30_ – 14_
1000 1000
= 30 –14
1000
= 16_
1000
Growth Rate = 16 per 1000 MYP (or) 1.6 %
D) Specific Mortality Rate for old people
Ans. Specific Mortality Rate for old people = No. of deaths of old people in one year x 1000
Mid Year Population of old people
= _1400_ x 1000
20000
= 70
Specific Mortality Rate for old people = 70 per 1000 MYP

E) Proportional Mortality Rate for old people……………… (33.3%)

Ans. Proportional Mortality Rate of old people = No. of deaths of old people in one year x 100
Total deaths in one year
= 1400_ x 100
4200
= 33.33
Proportional Mortality Rate for old people = 33.33%

7. Mortality observed in villages of India, Singapore and USA is given. Calculate the
proportational mortality rate. And comment

Total deaths 0-5 yr death

Singapore 400 10
India 450 143
USA 50 1

Proportional mortality rate(0-5yrs)= number of deaths in 0-5 yrs X 100

Total number of deaths
Proportional mortality rate of Singapore = 10/400 X 100= 2.5%
Proportional mortality rate of INDIA = 143/450 X 100= 31.75%
Proportional mortality rate of USA = 1/50 x 100 = 2%
Inference: Proportional mortality rate of under fives in India is approximately 15 times higher than in
Singapore and USA.

8. The following data was collected from a PHC with a mid-year population of 30,000. Calculate
General fertility rate, Age specific fertility rates and Total Fertility Rate from the given data.
Comment on the TFR.

Age group No of women Live births

15 – 24 2000 500
25 – 34 1800 250
35 – 44 1400 90
Total 5200 840
Solution:
General Fertility Rate = Total [Link] live births in an area during a year ∗ 1000
Mid year female population age 15−44(or 49)in the same area and same year
=840∗ 1000
5200
= 161.5 per 1000 women in the age group of 15-44 (or 49) years

Age Specific Fertility Rate (15-24) = no. of live births in a particular age (15−24)group ∗ 1000
Mid−year married female population of 15−24 age group
=500∗ 1000
2000

= 250 per 1000 women in the age group of 15-24 years

Age Specific Fertility Rate (25-34) = no. of live births in a particular age (25−34)group∗ 1000
Mid−year married female population of 25−34 age group
= 250∗ 1000
1800

= 138.8 = 139 per 1000 women in the age group of 25-34 years

Age Specific Fertility Rate (35-44) = no. of live births in a particular age (35−44)group ∗ 1000
Mid−year married female population of 35−44 age group
=90∗ 1000
1400

= 64.3 per 1000 women in the age group of 25-34 years

Total fertility rate = 5∗ Σ(ASFR)1000

= 5∗ (161.5+250+64.3)1000
= 5∗ 23791000= 2.3 The desired replacement level TFR is 2.1.

9. In the year 2019, ABC subcentre under XYZ PHC, covering a population of 5000 reported a
total of 600 fever cases were examined for malaria parasites, of which 400 were positive among
which 50 were falciparum cases and the rest were vivax cases. Calculate the API, ABER, Slide
positivity rate, Pf% & SfR and list the actions you would like to take as a MO to tackle the
problem of malaria in the area.
Solution:
Given
Total Population = 5000
Slides examined during 2019 = 600
No. positive for malaria parasite = 400
No. positive for falciparum malaria parasite = 50

I. Annual Parasite Incidence (API)

API = Confirmed cases during one-year X 1000

Population under surveillance

= 400 x 1000
5000

= 80 per 1000 population

API is ˃2, hence the area is a high-risk area for malaria.

API is a measure of malaria incidence in a community. It is based on intensive active and passive
surveillance. API depends upon the adequacy of ABER.

II. Annual Blood Examination Rate (ABER)-

Annual blood examination rate = No. of slides examined x 100

Population under surveillance

= 600 x 100
5000

= 12%

ABER is an index of operational efficiency. API depends on ABER. The aim is to screen 10% of the
population even if disease transmission is expected to reduce.

III. Slide Positivity Rate (SPR) -

Slide positivity rate = No of slides positive for malaria parasite x 100

No. of slides examined

= 400 x 100
600

= 66.66%
SPR is less dependent on ABER; It gives better indication of parasite load in the community. It is
more reliable than API when ABER fluctuates from year to year 35

IV. Slide Falciparum Rate (SfR)

SfR = Total No. of blood smears found positive for [Link] x 100
Total no. of blood smears examined

= 50 x 100
600

= 8.3%

SfR is less dependent on ABER; It pin points areas of [Link] preponderance for prioritizing
control measures

V. [Link] percentage (Pf%)

Pf % = Total no. of blood smears found positive for [Link] 100

Total no. of blood smears positive for malaria parasite

= 50 *100
400

= 12.5%

Pf % gives the relative proportion of [Link] infection and trends in relation to total case load.
Any rise in Pf % indicates breakdown of malaria control measures

List of actions to be taken –

a. Case management
b. Strengthen malaria surveillance
c. Vector control
d. Health education
e. Entomological assessment

10. An outbreak of food poisoning has been reported from the hostel of a college. Analysis of the
48 cases reported presents the following features. 40 cases have abdominal pain / nausea /
vomiting, 35 cases have salivation & prostration and 7 cases have subnormal temperature. All
cases had onset of symptoms on 3rd of November 2000. The time of food consumption was 1.00
pm. The total number of residents of the hostel is 50.
 Time of onset No of cases
2 pm- 2
3 pm -7
4 pm -15
5 pm -14
6 pm -06
7 pm -04

a) Find the attack rate

b) Draw an epidemic time curve.
c) What type of epidemic time curve is this?
d) Find the most likely agent for this outbreak.

Solution:

1. Attack rate = Number of cases * 100 = 48 x 100 = 96%

Total population 50

2. Figure 1: Epidemic curve showing single peak

c)Point source epidemic curve

d) Staphylococcus aureus & its enterotoxins (because of time of onset – 1 to 6 hrs, above symptoms
are seen in Staph aureus food poisoning)

11. In a district with an estimated midyear population (MYP) of 2 lakhs, there was an outbreak
of Hepatitis A infection following consumption of food in a religious meeting in the month of
October. 25 people had attended the meeting with 15 males & 10 females, 5 males developed
Hepatitis-A, over a period of 2 weeks. During the next 6 weeks, an additional three males & two
females developed the infection.
Calculate the attack rate and secondary attack rate of Hepatitis

Attack rate of Hepatitis = No of New cases of Hepatitis x 100

No of susceptible persons
= 5 x 100
25
= 20%

Secondary attack rate of Hepatitis:

= No of Susceptible persons affected x 100
No of Susceptible persons
= 5 x 100
20
= 25%

12. 10. A small town had a population of 9,900 on 1st January of a particular year (say, 2017).
The town’s mid-year population was 10,000. On 31st December of that year, the population was
10,100.
On 1st January of that year (2017), there were 200 cases of Tuberculosis (TB). During that year
40 new cases of TB were detected, 130 cases were cured, 10 cases died and 5 cases migrated to
other areas. Total number of deaths due to all causes in that year was 90.

Calculate the mortality and morbidity rates of TB for the year from the above data:

A) Incidence rate of TB:

Ans: Incidence of TB = No. of new cases of TB in one year x 1000

Mid-year population

= 40 x 1000
10000

= 4 per 1000 MYP

B) Period prevalence rate of TB of the year:

Ans: Period prevalence rate of TB = No. of old + new cases in one year x 1000
Mid-year population

= 200 + 40 x 1000 = 240_ x 1000

10,000 10,000
 = 24 per 1000 MYP

C) Point prevalence rate of TB on 31st December of that year:

Ans: Point prevalence rate of TB = No. of cases on 31st Dec. of one year x 1000
Population on 31st Dec. of the year
= Old cases + New cases – Cured – Death – Migration x 1000
10,100
= 200 + 40 – 130 – 10 – 5 x 1000 = 95_ x 1000
10,100 10,100
= 9.4 per 1000 population

D) Case fatality rate of TB:

Ans: Case fatality rate of TB = No. of deaths due to TB in one year x 100
Total No. of TB cases in that year
= 10 x 100 = 10 x 100 = 4.166%
200 + 40 240

E) Proportional Mortality Rate of TB:

Ans: Proportional Mortality Rate of TB = No. of deaths due to TB in one year x 100
No. of deaths due to all causes in the year
= 10 x 100 = 11.1%
90
SCREENING

[Link] true positives 𝑎

Sensitivity = Total [Link] diseased × 100 = 𝑎+𝑐 × 100

[Link] true negatives 𝑑

Specificity = Total [Link] people without disease × 100 = 𝑏+𝑑 × 100

[Link] true positives 𝑎

Positive predictive value (PPV) = Total [Link] people with screening test positive × 100 = 𝑎+𝑏 × 100

[Link] true negative 𝑑

Negative predictive value (NPV)= × 100 = 𝑐+𝑑 ×100
Total [Link] people with screening test negative

[Link] false negatives 𝑐

Percentage of False negatives (%FN) = × 100 = 𝑎+𝑐 × 100
Total [Link] people with disease
 [Link] false positives 𝑏
Percentage of False positive (%FP) = × 100 = 𝑏+𝑑 × 100
Total [Link] people without disease

Total [Link] people with the disease (a+ c)

Prevalence rate = × 100 = (a+b+c+d) × 100
Total population screened

1. A new screening test was done on 700 people of whom 90 were having disease Y. The test was
Positive in 75 of those with disease and 25 without disease. Construct a 2× 𝟐 𝒕𝒂𝒃𝒍𝒆 𝐚𝐧𝐝 calculate
sensitivity, specificity, positive and negative predictive values, percentage of false negative, false
positive and prevalence rate. Comment on the results.

(2× 𝟐 𝒕𝒂𝒃𝒍𝒆: 𝟐𝒎𝒂𝒓𝒌𝒔, 𝒇𝒐𝒓𝒎𝒖𝒍𝒂𝒔: 𝟑. 𝟓𝒎𝒂𝒓𝒌𝒔, 𝒄𝒂𝒍𝒄𝒖𝒍𝒂𝒕𝒊𝒐𝒏: 𝟑. 𝟓𝒎𝒂𝒓𝒌𝒔, 𝒄𝒐𝒎𝒎𝒆𝒏𝒕: 𝟏𝒎𝒂𝒓𝒌𝒔)-

------------------- 10marks

Solution:

Disease
Screening Test Total

Present Absent
Positive 75 (a) / TP 25 (b) / FP 100 (a+b)

Negative 15 (c) / FN 585 (d) / TN 600 (c+d)

Total 90 (a+c) 610 (b+d) 700 (a+b+c+d)

[Link] true positives 𝑎 75

i) Sensitivity = Total [Link] diseased × 100 = 𝑎+𝑐 × 100 = 90 × 100 = 83.33%

[Link] true negatives 𝑑 585

ii) Specificity = Total [Link] people without disease × 100 = 𝑏+𝑑 ×100 = 610 ×100 = 95.90%

[Link] true positives 𝑎 75

iii) PPV = Total [Link] people with screening test positive × 100 = 𝑎+𝑏 × 100 = 100 × 100 = 75%

[Link] true negative 𝑑 585

iv) NPV = × 100 = 𝑐+𝑑 ×100 = 600 × 100 = 97.5%
Total [Link] people with screening test negative
 [Link] false negatives 𝑐 15
v) %FN = × 100 = 𝑎+𝑐 × 100 = 90 × 100 = 16.6%
Total [Link] people with disease

[Link] false positives 𝑏 25

vi) %FP = × 100 = 𝑏+𝑑 × 100 = 610 × 100 = 4.1%
Total [Link] people without disease

Total [Link] people with the disease (a+ c) 90

vii) Prevalence rate = × 100 = (a+b+c+d) ×100 = 700 × 100 = 12.85%
Total population screened

Comment: Sensitivity of 83.33% implies that around 84 out of hundred with the disease will be
screened positive by the given test and a specificity of 95.90% implies that almost 96 out of 100 of
those without the disease will be screened negative by the given test. A 75% +ve predictive value
implies that 75 out of 100 individuals tested positive will actually have the disease. A 97.5% -ve
predictive value means that around 98 out of 100 individuals tested negative will actually not have the
disease.

2. A new screening test with sensitivity of 90%, specificity of 90% was done in a 1000 population
with prevalence of disease 5%. Construct a 2 x 2 table and positive predictive value, negative
predictive value and false positive and false negative values of the test. (2+2+2+2+2= 10marks)

Solution:
Total [Link] people with the disease
Prevalence rate = × 100
Total population screened

(Total no. of people with disease = Prevalence rate X Total population screened/100 )
5×1000
= = 50
100

[Link] true positives

Sensitivity = Total [Link] diseased × 100

[Link] true positives

90 = ×100
50

90×50
No. of true positives = = 45
100

[Link] true negatives

Specificity = Total [Link] people without disease × 100

[Link] true negatives

90 = × 100
950
 90×950
No. of true negatives = = 855
100

Disease

Screening Test
Present Absent Total

45 (a) / TP 95 (b) / FP
Positive 140

Negative 5 (c) / FN 855 (d) / TN 860

Total 950 [b+d] 1000

50 [a+c]

[Link] true positives 45

Positive predictive value (PPV) = Total [Link] people with screening test positive × 100 = 140 × 100 =
32.14%
[Link] true negative 855
Negative predictive value (NPV)= × 100 = 860 ×100 =
Total [Link] people with screening test negative
99.41%
[Link] false negatives 5
Percentage of False negatives (%FN) = × 100 = 50 × 100 = 10%
Total [Link] people with disease

[Link] false positives 95

Percentage of False positive (%FP) = × 100 = 950 × 100 = 10%
Total [Link] people without disease

3. The table shows the results obtained in a screening test for diabetes used on 10,000 people. A
blood glucose level of 180mg/100 ml above was considered to be diabetic. Calculate the following
parameters and comment on the results. (6+2= 8marks)

a) Sensitivity of the test.

b) Specificity of the test.
c) Predictive value of the positive test.
d) Predictive value of the Negative test.
e) Proportion of False Positives
f) Proportion of False Negatives.
 True Diagnosis
Screening test

Diabetic Non-diabetic Total

Positive 34 (a) 20 (b) 54

Negative 116 (c ) 9830 (d) 9946

Total 150 9850 10,000

Solution:

[Link] true positives 34

Sensitivity = Total [Link] diseased × 100 = 150 × 100 = 22.6%

[Link] true negatives 9830

Specificity = Total [Link] people without disease × 100 = 9850 × 100 = 99.7%

[Link] true positives 34

Positive predictive value (PPV) = Total [Link] people with screening test positive × 100 = 54 × 100 =
62.9%
[Link] true negative 9830
Negative predictive value (NPV)= × 100 = 9946 ×100 =
Total [Link] people with screening test negative
98.6%
[Link] false negatives 116
Percentage of False negatives (%FN) = × 100 = 150 × 100 = 77.3%
Total [Link] people with disease

[Link] false positives 20

Percentage of False positive (%FP) = × 100 = 9850 × 100 = 0.2%
Total [Link] people without disease

Comment:

Sensitivity of 22.6% implies that around 23 out of hundred diabetics will be screened positive by the
given test and a specificity of 99.7% implies that almost 100 out of 100 of non-diabetics will be
screened negative by the given test. A 62.9% +ve predictive value implies that 63 out of 100
individuals tested positive will actually have diabetes. A 98.8%-ve predictive value means that 99 out
of 100 individuals tested negative will actually not have diabetes.

4. Combination of mammography and physical examination was done on 31,000 women from
general population during 5-year period. From total screening 1,115 were declared positive on
whom biopsy were done which showed positive for ca-breast in 132 women. 45 cases were also
detected as positive, in whom screening test was negative. Calculate the following and comment
on the results. (6+2= 8marks)

a) Sensitivity of the test.

b) Specificity of the test.
 c) Predictive value of the positive test.
d) Predictive value of the Negative test.
e) Proportion of False Positives
f) Proportion of False Negatives.

Solution:

True Diagnosis
Screening test

Breast ca (+) Breast ca (-) Total

Positive 132 (a) 983 (b) 1,115

Negative 45 (c) 29,840 (d) 29,885

Total 177 30,823 31,000

[Link] true positives 132

Sensitivity = Total [Link] diseased × 100 = 177 × 100 = 74.5%

[Link] true negatives 29840

Specificity = Total [Link] people without disease × 100 = 30823 × 100 = 96.8%

[Link] true positives 132

Positive predictive value (PPV) = Total [Link] people with screening test positive × 100 = 1115 × 100 =
11.8%
[Link] true negative 29840
Negative predictive value (NPV)= × 100 = 29885 ×100 =
Total [Link] people with screening test negative
99.84%
[Link] false negatives 45
Percentage of False negatives (%FN) = × 100 = 177 × 100 = 25.42%
Total [Link] people with disease

[Link] false positives 983

Percentage of False positive (%FP) = × 100 = 30823 × 100 = 31.89%
Total [Link] people without disease

Comment:

Sensitivity of 74.5% implies that 76 out of 100 diseased will be screened positive by the given test.
Specificity of 96.8% implies that 97 out of 100 non-diseased will be screened negative by the given
test. 11.8%+ve predictive value means that 12 out of 100 individual screened will have the probability
of having the disease among those tested positive. 99.8%-ve predictive value means that almost all the
individuals (100) that were tested negative will have the probability of not having the disease.
5. A field study was carried out to evaluate the usefulness of a screening test for Cancer cervix.
The test was applied on 1000 women on whom histopathology examination was done which
identified 100 had Cancer cervix. The screening test correctly identified 80 women as having
Cancer cervix and gave a false positive result in respect of another 25 women. Construct a 2 x 2
table and calculate the sensitivity, specificity, predictive values and percentage of false positives
and false negatives. (2+6= 8marks)

Solution:

Disease Positive Disease Negative TOTAL

Test Positive 80 (a)/TP 25 (b)/FP 105 (a + b)

Test Negative 20 (c)/FN 875 (d)/TN 895 (c + d)

TOTAL 100 (a + c) 900 (b + d) 1000 ( a +b + c + d)

[Link] true positives 80

Sensitivity = Total [Link] diseased × 100 = 100 × 100 = 80%

[Link] true negatives 875

Specificity = Total [Link] people without disease × 100 = 900 × 100 = 97.3%

[Link] true positives 80

Positive predictive value (PPV) = × 100 = × 100 =
Total [Link] people with screening test positive 105
76.2%
[Link] true negative 875
Negative predictive value (NPV)= × 100 = 895 ×100 =
Total [Link] people with screening test negative
97.7%
[Link] false negatives 20
Percentage of False negatives (%FN) = × 100 = 100 × 100 = 2.78%
Total [Link] people with disease

[Link] false positives 25

Percentage of False positive (%FP) = × 100 = 900 × 100 = 20%
Total [Link] people without disease

Inference:

. Sensitivity of the screening test – 80 %

. Specificity of the screening test – 97.3 %
. Positive predictive value of the screening test – 76.2 %
. Negative predictive value of the screening test –97.8 %
. False – positive of the screening test- 2.78 %
. False – negative of the screening test- 20 %
6. Consider 100 patients suspected of having pulmonary tuberculosis in the community. The
technician examined single sputum smear and 30 contained AFB (acid fast bacilli). On
subsequent culture of these 100 it was found that 35 patients were positive for pulmonary
tuberculosis and among them 25 patients were smear positives (on microscopy). Construct a 2 x
2 table and calculate the sensitivity, specificity, predictive values and percentage of false
positives and false negatives. (2+6= 8 marks)

Solution:

Disease Positive Disease Negative TOTAL

Test Positive 25 (a) 5 (b) 30 (a + b)

Test Negative 10 (c) 60 (d) 70 (c + d)

TOTAL 35 (a + c) 65 (b + d) 100 (a +b + c + d)

[Link] true positives 25

Sensitivity = Total [Link] diseased × 100 = 35 × 100 = 71.42%

[Link] true negatives 60

Specificity = Total [Link] people without disease × 100 = 65 × 100 = 92.3%

[Link] true positives 25

Positive predictive value (PPV) = × 100 = × 100 =
Total [Link] people with screening test positive 30
83.33%
[Link] true negative 60
Negative predictive value (NPV)= × 100 = 70 ×100 =
Total [Link] people with screening test negative
85.71%
[Link] false negatives 10
Percentage of False negatives (%FN) = × 100 = 35 × 100 = 28.57%
Total [Link] people with disease

[Link] false positives 5

Percentage of False positive (%FP) = × 100 = 65 × 100 = 7.69%
Total [Link] people without disease

Inference

. Sensitivity of the screening test – 71.42%

. Specificity of the screening test – 92.30%
. Positive predictive value of the screening test – 83.33%
. Negative predictive value of the screening test – 85.71%
. False – positive of the screening test- 7.69%
. False – negative of the screening test- 28.57 %
7. A new screening tool for diabetes was used in a community among a sample of 100 individuals
of which 30 were confirmed to have diabetes by the gold standard test (oral glucose tolerance
test). The new tool identified 20 of these individuals to be true positives and 10 of them to be
false positives. Construct a 2 x 2 table and calculate sensitivity, specificity, predictive values and
percentage of false positives and false negatives.

Solution:

Diabetes Positive Diabetes Negative TOTAL

Test Positive 20 (a) 10 (b) 30 (a + b)

Test Negative 10 (c) 60 (d) 70 (c + d)

TOTAL 30 (a + c) 70 (b + d) 100 (a +b + c + d)

[Link] true positives 20

Sensitivity = Total [Link] diseased × 100 = 30 × 100 = 66.67%

[Link] true negatives 60

Specificity = Total [Link] people without disease × 100 = 70 × 100 = 85.71%

[Link] true positives 20

Positive predictive value (PPV) = × 100 = × 100 =
Total [Link] people with screening test positive 30
66.66%
[Link] true negative 60
Negative predictive value (NPV)= × 100 = 70 ×100 =
Total [Link] people with screening test negative
85.71%
[Link] false negatives 10
Percentage of False negatives (%FN) = × 100 = 30 × 100 = 33.33%
Total [Link] people with disease

[Link] false positives 10

Percentage of False positive (%FP) = × 100 = 70 × 100 = 14.28%
Total [Link] people without disease

Inference

 Sensitivity of the screening test – 66.67%

 Specificity of the screening test – 85.71%
 Positive predictive value of the screening test – 66.66%
 Negative predictive value of the screening test – 85.71%
 False – positive of the screening test- 14.28%
 False – negative of the screening test- 33.33%
8. The validity of a new screening test for typhoid fever was assessed using the blood culture as
gold standard. Of the 400 individuals with fever for 4 days or more, 50% grow salmonella in the
blood culture. The screening test was positive in 60% of the total subjects. The positive
predictive value was found to be 75%. Construct a 2 x 2 table and calculate sensitivity and
specificity of the screening test and suggest a method of improving the positive predictive value
of the test. (3+2+1= 6marks)

Solution:

60% of 400 = 240 individuals with test positive

50% 0f 400 = 200 individuals with the disease

Disease Total

+ -

Screening test + 180 (a) 60 (b) 240

- 20 (c) 140(d) 160

Total 200 200 400

[Link] true positives 𝑎

Positive predictive value (PPV) = × 100 = × 100
Total [Link] people with screening test positive 𝑎+𝑏

𝑎
75 = 240 × 100

𝑎 = 180
[Link] true positives 𝑎 180
Sensitivity = Total [Link] diseased × 100 = 𝑎+𝑐 = 200 × 100 = 90%

[Link] true negatives 𝑑 140

Specificity = Total [Link] people without disease × 100 = 𝑏+𝑑 = 200 × 100 = 70%

Positive predictive value of the test can be increased by increasing the sensitivity of the test i.e., by
increasing the number of true positives

NUTRITION PROBLEMS

N1. Prescribe a balanced diet for a family consisting of adult male doing construction labour
work, housewife and two children aged 3 and 6 years old.

SOLUTION →

Energy coefficient calculation

Father = Labourer = Heavy worker = 1.2

Mother = Housewife = 0.8

Child of 6 yrs child = 0.6

Child of 3 yrs child = 0.4

Total = 1.2 + 0.8 + 0.6 + 0.3 = 3

Food stuffs Quantity Total

Cereals 460g x 3 1380g

Pulses 40g x 3 120g
Green leafy vegetables 40g x 3 120g
Other vegetables 60g x 3 180g
Roots and tubers 50g x 3 150g
Milk and milk product 150g x 3 450g
Oils and fats 40g x 3 120g
Sugar and Jaggery 30g x 3 90g

N2. A 14 year old vegetarian student is being given the meals containing following components
daily. Comment on quality and quantity of diet and suggest improvement if any.

Rice: 200 grams, Wheat: 50 grams, Pulses: 20 grams, Hydrogenated oil: 20 grams, Green leafy
vegetables: 45 grams, Onion: 20 grams, milk and milk product: 100 grams, sugar: 20 grams

Solution: The energy co-efficient of the student is 1.

Food Items Quantity Required [g/day] Quantity Consumed [g/day] Deficient/Excess [g/day]
Cereals 460g x 1 = 460 250 - 210
Pulses 40g x 1 = 40 20 -20
Green leafy vegetables 40g x 1 = 40 45 +05
Other vegetables 60g x 1 = 60 ─ - 60
Roots and tubers 50g x1 = 50 20 - 30
Milk and its products 150g x 1 = 150 100 - 50
Oils and fats 40g x1 = 40 20 - 20
Sugar and jaggery 30g x1= 30 20 - 10
Inference: The diet does not contain other vegetables (-60g/day), it is deficient in cereals

(-210g/day), pulses (-20g/ day), roots and tubers (-30g/day), milk and milk products (-50g/day),

Fats and oils (-20g/day), sugars and jaggery (-10g/day). The needs for green leafy vegetables are adequately met.

Comment: The diet as a whole is poor in quality as well as quantity.

Improvements: The diet should contain the following components in addition

Other vegetables (+60g/day), roots and tubers (+30g/day), cereals (+210g/day),pulses (+20g/ day)

Milk and milk products (+50g/day), fats and oils (+20g/day), sugar and jaggery (+10g/day).

N3. Construct a balanced diet for a family consisting of a 32 year old weaver, 28 year old wife
who is a Beedi maker planning to conceive and 2 ½ years old female child.

SOLUTION: The energy co-efficient for the given family is

Energy co-efficient of the father = 1.
Energy co-efficient of the mother = 0.9
Energy co-efficient of the child = 0.
Total = 1.2 + 0.9 + 0.4 = 2.5

Food stuffs Quantity Required Total [g/day]

Cereals 460g x 2.5 1150
Pulses 40g x 2.5 100
Green leafy vegetables 40g x 2.5 100
Other vegetables 60g x 2.5 150
Roots and tubers 50g x 2.5 125
Milk and milk products 150g x 2.5 375
Oils and fats 40g x 2.5 1
Sugar and Jaggery 30g x 2.5 75

N4. Each male prisoner aged between 20- 39 yrs each day jail is given the following vegetarian
diet. Comment on the quality and quantity of the diet & suggest improvements as needed.

Rice – 300g
Pulses – 50g
Hydrogenated oil – 25g
Green leafy vegetables – 50g
SOLUTION → Total energy co-efficient → 1.2

Food Item Quantity Required [g/day] Quantity Consumed Deficient/Excess

Cereals 460g x1.2 = 552 300g - 252g
Pulses 40g x1.2 = 48 50g + 2g
Green leafy vegetables 40g x1.2 = 48 50g + 2g
Other vegetables 60g x1.2 = 72 ─ - 72g
Roots and tubers 50g x1.2 = 60 ─ - 60g
Milk and its products 150g x1.2 = 180 ─ - 180g
Oils and fats 40g x1.2 = 48 25g - 23g
Sugar and Jaggery 30g x1.2 = 36 ─ - 36g
Inference → This diet does not contain other vegetables (72g), roots and tubers (60g), Milk and its
product (180g), Sugar and Jaggery (36g). It is deficient in cereals (-252g), fats and oils (- 36g). The
diet provides adequate quantities of pulses (+2g) and green leafy vegetables (+2g),
Comment → Diet is poor in both quality and quantity.

Improvements → Diet should contain other vegetables (72g), roots and tubers (60g).

Milk and its products (180g) and Sugar and Jaggery(36g) on a daily basis.

WATER PROBLEMS

W1. A half-filled rectangular well measuring 15 feet length, 10 feet breadth and 10 meters depth
is to be disinfected. The Horrocks test shows blue color in 5th and 6th cups. Calculate the quantity
of bleaching powder required to disinfect the well. What are water-related diseases? Add a note
about OT test.

SOLUTION

Length - 15 feet = 4.572 meters (1 foot= 0.305 meters)

Breadth - 10 feet = 3.048 meters

Depth - 10 meters = 10/2 (Half filled) = 5 meters

Volume of water = L x B x H = 4.572 x 3.048 x 5

= 69.675 cu.m (1 cu.m = 1000 liters) = 69675 liters

Blue colour - 5th cup,

For 455 liters of water, requires (2n) = 5 x 2 = 10 mg of bleaching powder

So, 69675 liters requires 69675 x 10 /455 = 1531.31 g = 1.531 kg

Water-related diseases transmitted by insect vectors that breed in water.

Example: Yellow Fever, Dengue, Filariasis, Malaria, Chikungunya.

OT test

Orthotoluidine test enables both free and combined chlorine in water to be determined

Reagent – analytical grade orthotoluidine dissolved in 10% solution of hydrochloride acid

Procedure

Add 0.1 ml of the reagent to 1ml of water .When this reagent is added to water containing chlorine it
turns yellow and intensity of color varies with the concentration of gas. Yellow color is produced by
both free and combined chlorine residual.
OT reacts with free chlorine instantaneously but reacts more slowly with combined chlorine. The
yellow colour produced is matched against suitable standards or colour discs. It is essential to take the
reading within 10 seconds after addition of reagent to estimates free chlorine in water

The color that is produced after a lapse is due to action of both free and combined chlorine

W2. Give a detailed report on this water sample and state whether it is potable:
Total Solids 250 ppm
Total Hardness 180 ppm
Free Ammonia 0.244 ppm
Albuminoid ammonia 0.81 ppm
Nitrites 0.005 ppm
Nitrates 21.0 ppm
Chlorides 45.00 ppm
Coliform count 15/100 ml
SOLUTION:
Characteristics Quantity Normal Value Interpretation
Total solids 250 ppm 1000 ppm Within normal limit
Total hardness 180 ppm 300 ppm Within normal limit
Free Ammonia 0.244 ppm <0.05 ppm Excess indicates recent sewage
contamination, industrial waste
contamination, decomposition
of organic matter by the
organisms present in it
Albuminoid ammonia 0.81 ppm 0.1 ppm Indicates undecomposed
organic matter with recent
pollution
Nitrites 0.005 ppm 3 ppm Within normal limit
Nitrates 21 ppm 50 ppm Within normal limit
Chlorides 500 ppm 200 – 600 ppm Within normal limit
Coliform organisms 15/100 ml 0 / 100 ml Excess count indicates faecal
water contamination
Inference:
Free ammonia, Albuminoid ammonia and Coliform count are more than recommended for potable
purpose. Therefore, this water is unfit for drinking purpose.

W3. Calculate the amount of bleaching powder with 25% available chlorine required to disinfect
a swimming pool measuring 30 x 20 x 10 feet to bring a chlorine concentration of 2 ppm. Name
any five swimming pool borne diseases. What are the indications of super-chlorination.

SOLUTION:-

Dimensions = Length = 30 feet, B = 20 feet, H = 10 feet

Volume of water = L x B x H = 30 x 20 x 10cu feet

= 6000 cu feet (1 cu feet = 6.25 gallons) = 6000 cu feet = 6.25 x 6000

= 37,500 gallons (1 gallon= 4.55 liters) = 37500 x 4.55 = 1,70,625

liters

1 mg of 25% bleaching powder in 1 liter = ¼ ppm

4 mg of 25% bleaching powder in 1 liter – 1ppm

4 x 2mg = 8 mg of 25% of bleaching powder in 1 liter = 2ppm

So, 1,70,625 liters requires = 1,70,625 x 8 mg= 13,65,000mg = 1365 g = 1.365 kg

Swimming pool borne diseases  Conjunctivitis, Sinusitis, Otitis Media, Infection Sore throat,
Athlete Foot

b) Indications for superchlorination

1) When the water is heavily contaminated.

2) Threatening outbreak of water borne epidemics.

W4. Following are the results of 2 samples of drinking water analyzed at district public health
laboratory

Sample A: Sparklingly clear, Nitrites- Traces, Chlorides- 600ppm, E-Coli – 12/100ml

Sample B: Turbid, Nitrites – Absent, Chlorides- 100ppm, E-Coli – 1/100ml.
Interpret the results and give the normal standards of water in India.
SOLUTION:

Parameter A B Reference value Inference

Turbidity clear turbid < 5 NTU B is not acceptable
Colour - - < 15 TCU -
Ph - - 6.5 – 7.5 -
Chlorides 600 100 < 600mg/lit A is not acceptable
TDS - < 1000mg/lit
Nitrates - < 50mg/lit
Nitrites Traces absent < 3mg/lit Acceptable
Fluorides - - 0.5 - 1.5mg/lit
Lead - - < 0.01mg/lit
Total hardness - - 50 – 150mg/lit
Sulphates - - < 250 mg/lit
Coliforms 12/100 ml 1/100ml Nil not acceptable
Interpretation: The water is not fit for drinking purposes as both samples show the presence of
coliform organisms.
BIOSTATISTICS

1. The fasting blood sugar of 10 individuals was 83, 75, 81, 99, 71, 90, 75, 95, 77, 84. Calculate the
a) range b) standard deviation. What is the significance of calculating standard deviation?

Solution: On arranging the values in ascending order: 71, 75, 75, 77, 81, 83, 84, 90, 95, 99

a) Range= highest – lowest value

= 99 – 71 = 28
Mean = Sum of all the observations
Total number of observations

Mean(X̄) = 830 / 10 = 83

FBS (X) X̄ Difference (X- X̄) (X- X̄) 2

71 -12 144
75 -8 64
75 -8 64
77 -6 36
81 -2 4
Mean(X̄)= 83
83 0 0
84 1 1
90 7 49
95 12 144
99 16 256
762

b) Standard deviation= √ ∑(X-X̄)2)/n-1 = √ 762/10-1= √762/9= √ 84.66= 9.2

Significance of calculating standard deviation

 It is an abstract number
 It gives us an idea of the 'spread' of the dispersion
 Larger the standard deviation, the greater the dispersion of values about the mean
 It is the best and most powerful tool of dispersion
 It is affected least by fluctuations of sampling

2. The marks obtained by the student in a school at the internal assessment were as follows:

24 35 38 23
26 33 36 20
34 38 42 38
a. Calculate the Mean, Median, Mode
b. Calculate the Standard deviation and coefficient of variation.
Solution:

Mean = Sum of all the observations

Total number of observations

Mean(X̄)= 387/12 =32.25

Median: On arranging the above data in ascending order: 20 23 24 26 33 34 35 36 38 38

38 42

Median: 34+35 = 34.5

Mode=38

No of days X̄
Difference (X- X̄) (X-X̄)2
(X)
24 -8.25 68.06
35 2.75 7.56
38 5.75 33.06
23 -9.25 85.56
26 -6.25 39.06
33 0.75 0.56
36 3.75 14.06
20 Mean(X̄)= 32.25 -12.25 150.06
34 1.75 3.06
38 5.75 33.06
42 9.75 95.06
38 5.75 33.06
562.25

Standard deviation= √ ∑(X-X̄)2/n-1 = √ 562.22/12-1= √562.22/ 11= √ 51.11= 7.15

Co-efficient of variation = Standard Deviation x 100

Mean

= 7.15 x 100
32.25
=22.17 percent.

Inference:

Mean =32.35
Standard deviation= 7.15
Coefficient of variation =22.17

3. Apply the Chi -Square Test to the find the efficacy of the drug from the data given below.

Given Data

Died Survived

Placebo 10 25 35
A b
N1

Trial Drug 5 60 65
C d
N2

15 85 100

• N1 = 35 – no. of subjects who were given placebo

• a = 10 - subjects who were given placebo and those who died
• b = 25 - subjects who were given placebo and those who survived
• N2 = 65 – no. of subjects who were given the trial drug
• c = 5 - subjects who were given the trial drug and those who died
• d = 60 - subjects who were given the trial drug and those who survived

Conditions

• Count data
• Two group of individuals
• The observation (survival) is independent – unmatched patient in two groups
• Therefore, Chi – square is to be applied
Test statistics: Chi- square test

Desired level of significance: 5% of significance

Null hypothesis

There is no difference in the survival rate of the subjects from the study between treatment groups.
Calculating the chi – square value
Died Survived

Placebo
C2 25
C1 10 HT1 35

Trial Drug
C3 5
C4 60 HT2 65

VT1 VT2 GT
15 85 100

Part – I: Calculating Proportions

Proportion of patients who had placebo = C1 x 100 = 10 X 100 = 28.57%

& those who died HT1 35

Proportion of patients who had placebo = C2 x 100 = 25 X 100 = 71.42%

& those who survived HT1 35

Proportion of patients who had trial drug = C3 x 100 = 5 X 100 = 7.69%

& those who died HT2 65

Proportion of patients who had trial drug = C4 x 100 = 60 X 100 = 92.30%

& those who survived HT2 65

Part – II: calculate the Expected frequency for each cell (E)

C1 = HT1 X VT1 / GT= (35 x 15) / 100 = 5.25 (E)

C2 = HT1 X VT2 / GT = (35 x 85) / 100 = 29.75 (E)

C3 = HT2 X VT1/ GT = (65 x 15) / 100 = 9.75 (E)
C4 = HT2 X VT2/ GT = (65 x 85) /100 = 55.25 (E)

Part – III: Calculate the chi – square value for each cell
Chi – square = ∑(O-E)2
E
Where ‘O’ is the observed frequency and

‘E’ is the expected frequency

 chi – square
Observed Expected
(𝑂 − 𝐸)2 value for
Cell value value
each
𝐸
(O) (E)
cell

(10 -5.25 )2
C1 10 5.25 4.29
5.25

(25 -29.75 )2
C2 25 29.75 0.76
29.75

(5 -9.75 )2
C3 5 9.75 2.31
9.75

(60 -55.25 )2
C4 60 55.25 0.408
55.25

Sum up all
the Chi (𝑂 − 𝐸)2
∑( ) 7.77
square 𝐸
values

Chi – square value = ∑(O-E)2 / E = 7.77

Part – IV: - Degree of freedom = (r-1) x (c-1) = 1

Part – V: Interpreting the chi – square test

Statistical inference

o Table value of chi – square at 5% level at 1 degree of freedom is 3.84. The calculated value of
chi – square is (7.77) more than the table value. Therefore, we reject the Null Hypothesis.

o The observed difference of survival rate of the patients among those treated with trial drug are
more than the patients treated with placebo is statistically significant and it could not be
occurred by chance.

Interpretation:

o Treatment with trial drug is significantly associated with better survival rate among study
subjects.
4. In the prospective study of singleton births to mothers who conceived following IVFU (in-vitro
feralization) the following data were observed on hypertension during pregnancy and low birth
weight.

Low birth Normal birth weight Total

< 2500 gm 2500+ gms

Hypertension 27 (a) 62 (b) 89 (a+b)

No Hypertension 53 (c) 499 (d) 552 (c+d)
Total 80 (a+c) 61 (b+d) 641 (a+b+c+d)

a. Examine the relationship between hypertension during pregnancy and birth weight.

Null hypothesis: There is no relation between hypertension and low birth weight.

Part –I: Calculate the Expected frequency for each cell (E)

Expected value of a cell can be calculated using the

formula= row total*column total/grand total

The expected values are

a=89*80/ 641= 11.1

b=89*561/ 641= 77.8

c=552*80/ 641= 68.8

d=552*561/ 641= 483

Part – II: Calculate the chi – square value for each cell

Chi – square = ∑(O-E) ^2/E

= (27-11.1) ^2/ (11.1) + (62-77.8) ^2/ (77.8) + (53-68.8) ^2/ (68.8) +(499-483) ^2 / (483)

= 22.77+ 0.41+ 3.68+ 0.53

Part III: Chi square=27.33

Part – IV: - Degree of freedom = (r-1) x (c-1) = 1

Part – V: Interpreting the chi – square test

Statistical inference

Table value of chi – square at 5% level at 1 degree of freedom is 3.84.

The calculated value of chi – square is 27.33, which is more than the table value.

Therefore, we reject the Null Hypothesis.

The observed difference between Hypertension among mother and low birth weight among babies is
statistically significant and it could not have occurred by chance.

Interpretation:

Presence of hypertension in the antenatal period is significantly associated with Low birth weight in
the baby.

5. The duration of illness in days in a group of patients suffering from Upper respiratory tract
infection in given below.
9 8 6
7 4 8
11 6 8
9 12 5

Calculate Median, Mode and Standard Deviation.

Answer: On arranging the above data in ascending order: 4, 5, 6, 6, 7, 8, 8, 8, 9, 9, 11, 12

Median= 8+8/2 = 16/2 = 8

Mode= 8

Mean (X̄) = Sum of all the observations/Total no. of observations

Mean= 93/ 12= 7.75

No of days Difference
X̄ (x- X̄)2
(x) (x- X̄)

4 -3.75 14.06

5 -2.75 7.56
Mean(X̄)=
6 -1.75 3.06
7.75
6 -1.75 3.06

7 -0.75 0.56
 8 0.25 0.06

8 0.25 0.06

8 0.25 0.06

9 1.25 1.56

9 1.25 1.56

11 3.25 10.56

12 4.25 18.06

* * 60.22

Standard deviation= √ ∑ (x- X̄)2 / n-1= √ 60.22/ 12-1= √60.22/ 11= √ 5.47= 2.34

Inference:
- Mean= 7.75
- Median= 8
- Mode= 8
- SD= 2.34

6. Following table shows the data on the daily attendance at one of the PHC recorded for the
month of July 2020

Consultation Consultation Consultation

60 80 72
77 71 89
65 108 75
90 102 80
80 85 88
105 79 90
80 97 77
85 87 90
a. Calculate the mean, mode and median for daily attendance

Solution:

On arranging the number of consultations in ascending order:

60 65 71 72 75 77 77 79 80 80 80 80 85
85 87 88 89 90 90 90 97 102 105 108
Total number of days = 24

Total attendance = 2019

Mean = Sum of all the observations /Total no. of observations

Mean= 2019/24

= 83. 83
Median = (80+85)/2= 82.5
Mode= 80

7. Serum bilirubin levels (mgs / dl) of 10 patients admitted to a hospital for treatment of hepatitis
–B, were found to be 20.5, 14.8, 21.3, 12.5, 15.2, 26, 23.4, 22.9, 15, 19. Calculate the arithmetic
mean and standard deviation.

Solution
Number of study subjects (N) = 10

x (x- X̄) (x- X̄)2

X̄
20.5 1.44 2.0736
14.8 -4.26 18.1476
21.3 2.24 5.0176
12.5 -6.56 43.0336
15.2 Mean(X̄) -3.86 14.8996
26 = 19.06 6.94 48.1636
23.4 4.34 18.8356
22.9 3.84 14.7456
15 -4.06 16.4836
19 -0.06 0.0036
181.404

Mean= X̄ = ∑xi/N

=19.06

Standard deviation= √ ∑ (x- X̄)2 / n-1

=√181.404/10-1

=1.49
8. The following is the distribution of age at the time of first delivery among women.

Find the mean deviation from the mean.

Age 20 24 28 32 36

No of 20 30 11 3 1
Women

Solution:

Mean(X̄)= ∑fx/N

= 1560/65 = 24 years

x f fx X̄ |x- X̄| f|x- X̄|

20 20 400 4 80
24 30 720 0 0
28 11 308 4 44
Mean(X̄)
32 3 96 8 24
=24
36 1 36 12 12
∑f=
∑fx=1560 160
65

The mean deviation from the mean is

MD(X̄)= ∑f|x- X̄|/N where, N=∑f

= 160/65 = 2.46 years

9. Consider the following data on serum cholesterol along with the frequency for each.

Serum 120 130 140 150 160 170 180 190 200
cholesterol
level(x)
No of 15 78 273 369 341 207 133 43 11
subjects
(f)

Calculate mean.

Solution:

x f xf
120 15 1800
 130 78 10140
140 273 38220
150 369 55350
160 341 54560
170 207 35190
180 133 23940
190 43 8170
200 11 2200
1470 229570

Mean = ∑fx/N
=229570/1470
= 156.17
Thus, the mean yield per tree is 156 coconuts per tree.

10. The following data represent the weights (in kilograms) of a group of patients.

70, 72, 68, 75, 80, 77, 71, 74

Calculate variance and coefficient of variance.

Solution:

Mean = ∑x/N = X̄ = (70+72+68+75+80+77+71+74)/8

= 587/8 = 73.37

x X̄ (x-X̄) (x-X̄)2
70 -3.375 11.39063
72 -1.375 1.890625
68 -5.375 28.89063
75 1.625 2.640625
80 Mean 6.625 43.89063
̄
(X)=73.37
77 3.625 13.14063
71 -2.375 5.640625
74 0.625 0.390625
107.87

Variance (s2) = ∑ (x- X̄)2/n-1

=107.87/8-1 = 15.41
Standard Deviation(s) = √s2 = 3.92
 Coefficient of variance cv= (s/ X̄) *100
= (3.92/73.37) * 100 = 5.34 %

11. In a study assessing the effectiveness of a new cholesterol-lowering therapy, what is the
significance of the observed changes in participants' serum cholesterol values before and after
the treatment?

subject Before After

no therapy(d1) therapy(d2)
1 306 280
2 254 242
3 198 204
4 242 238
5 236 228
6 228 202
7 286 264
8 274 258
9 208 209
10 188 198

Solution:

Difference
subject Befor After
di=(d2- d`` (di-d``) (di-d``)^2
no therapy(d1) therapy(d2)
d1)
1 306 280 -26 -9.7 -16.3 265.69
2 254 242 -12 -9.7 -2.3 5.29
3 198 204 6 -9.7 15.7 246.49
4 242 238 -4 -9.7 -4 16
5 236 228 -8 -9.7 1.7 2.89
6 228 202 -26 -9.7 -16.3 265.69
7 286 264 -22 -9.7 -12.3 151.29
8 274 258 -16 -9.7 -6.3 39.69
9 208 209 1 -9.7 10.7 114.49
10 188 198 10 -9.7 19.7 388.09
-97 1495.61

Mean difference= ∑ (d2-d1)/10 = -97/10= -9.7

S.D. difference = √ [∑(di-d``)2/(n-1)]

• xdiff: sample mean of the differences = -9.7

 • s: sample standard deviation of the differences = 12.96
• n: sample size (i.e., number of pairs) = 10

hypotheses:

H0: μ1 = μ2 (the two-population means are equal)

H1: μ1 ≠ μ2 (the two-population means are not equal)

Calculate the test statistic t

t = xdiff / (sdiff/√n) = -9.7 / (4.09/√10) = -2.36

Calculate the p-value of the test statistic t

According to the t-score to p-value calculator, the p-value associated with t = -2.36 and degrees of
freedom = n-1 = 10-1 = 9 p- table value =0.05

Conclusion:

Since this p-value is less than our significance level α = 0.05, we reject the null hypothesis.

i.e., t-calculated<P-table value, -2.36 < 0.05

12. In the hospital 12 patients were subjected to ESR estimation. The data were as follows,
calculate the mean, Median and Mode.

ESR (mm/hr) of 12 arthritis patients:

35, 33, 32, 30, 36, 31, 63, 37, 30, 34, 72, 35

Solution:

Time taken (in hrs) 1-3 3-5 5-7 7-9

Arranging in order 30,30,31,32,33,34,35,35,36,37,63,72

∑𝑥𝑖
Mean (𝑥̅ ) = = 468/12 = 39
𝑛

Median M={(n+1)/2}th = (12+1)/2 = 6.5th = 34.5

Mode Z = most repeated frequency = 30 & 35

1. In a study to estimate the time taken to get complete relief from fever after administrating an
antipyretic drug (acetaminophen) the following data were obtained. Calculate the arithmetic
mean, median and mode.
 No of patients 12 20 4 4

SOLUTION:

CLASS f x-Mid value fx Cumulative

INTERVAL frequency

1-3 12 2 24 12

3-5 20 4 80 32

5-7 4 6 24 36

7-9 4 8 32 40
Median
Class Total ∑f= 40 ∑fx= 160

∑𝑓𝑖𝑥𝑖
Mean (𝑥̅ ) = = 160/40 = 4
𝑁

𝑁 40
−𝐶𝐹 −12
2 2
Median M = 𝑙 + ( )∗𝐶 =3+( ) ∗ 2 = 3.8
𝑓 20

1 0 𝑓 −𝑓 20−12
Mode Z= 𝐿 + (2𝑓 −𝑓 ) = 3 + (2∗20−12−4) = 3.66
−𝑓1 0 1

13. Calculate the mean deviation of the body mass index (BMI) of 10 patients attending urban
health centre of CDSIMER. The BMI (kg/m2) of 10 patients is as below.

22, 18, 24, 26, 28, 20, 23, 25, 18, 27

SOLUTION:
∑𝑥𝑖
Mean (𝑥̅ ) = = 231/10 = 23.1
𝑛

x 𝑥̅ |x-𝑥̅ |

22 1.1

18 5.1

24 0.9

26 2.9
 28 23.1 4.9

20 3.1

23 0.1

25 1.9

18 5.1

27 3.9

𝛴 |x-𝑥̅ |=29

𝛴|𝑥−𝑥̅ |
Mean Deviation MD(x) = 𝑛
= 29/10= 2.9

14. The Hb gm% of 100 female patients admitted in the CDSIMER hospital is given below
calculate the mean deviation.

CI 5-7 7-9 9-11 11-13 13-15

No of female patients 10 20 40 20 10

SOLUTION:
CI f x fx 𝑥̅ |x-𝑥̅ | f*|x-𝑥̅ |
5-7 10 6 60 4 40
7-9 20 8 160 2 40
9-11 40 10 400 ∑𝑓𝑖𝑥𝑖 0 0
= 10
𝑁
11-13 20 12 240 2 40
13-15 10 14 140 4 40
Total Σf = 100 ∑fx=1000 ∑f*|x-𝑥̅ |=
160

∑𝑓𝑖𝑥𝑖
Mean = = 1000/100 = 10
𝑁

𝛴|𝑥−𝑥̅ |
Mean Deviation MD(x) = = 160/100= 1.6
𝑛
15. The CD4 count of 50 HIV patients is given below calculate the standard deviation, coefficient
of variance.

CI 100-200 200-300 300-400 400-500 500-600

Patients 6 14 10 8 12

SOLUTION:

CI f x fx (x-X) (x-X)2 f(x-X)2

100-200 6 150 900 -212 44944 269664

200-300 14 250 3500 -112 12544 175616

300-400 10 350 3500 -12 144 1440

400-500 8 450 3600 88 7744 61952

500-600 12 550 6600 188 35344 424128

TOTAL ∑f=50 ∑fx=18100 ∑ f(x-

X)2=932800

𝛴𝑓𝑥 18100
𝑀𝑒𝑎𝑛(𝑥̅ ) = = = 362
𝑁 50

Variance(s2) = ∑f(X-X)2/N = 932800/50 =18656

SD= √18656 = 136.586

̅̅̅ ∗ 100 = (136.586/362) *100
Coefficient of variance= (SD/𝑋)

= 37.731

16. A group of medical students conducted a study to assess the average resting heart rate in a
population. They hypothesized that the average resting heart rate in their sample would be 70
beats per minute, based on existing literature. They collected data from a random sample of 30
individuals and found that the average resting heart rate in their sample was 72 beats per
minute with a standard deviation of 5 beats per minute. Calculate the one sample t-test.

SOLUTION:
Step 1: Gather the sample data.
• Sample size n = 30
• Population mean weight= 70
• Sample mean weight x = 72
• Sample standard deviation s = 5
Step 2: Define the hypotheses.
We will perform the one sample t-test with the following hypotheses:
• H0: μ = 70 (average resting heart rate is equal to 70)
• H1: μ ≠ 70 (average resting heart rate is not equal to 70)

Step 3: Calculate the test statistic t.

x−μ 72−70
t= s = 5 = 2.19
√n √30
the p-value associated with t = 2.19 and degrees of freedom(df) = n-1

= 30-1
= 29 is 1.699
Since t-table value is less then calculated value, we reject null hypothesis

conclude that the average resting heart rate in the sample of 30 individuals is statistically significantly
different from the hypothesized population mean of 70 beats per minute.

17. A pharmaceutical company is testing the effectiveness of two different drugs, A and B, in
reducing blood pressure. They randomly assigned 10 participants to receive drug A and another
10 participants to receive drug B. After four weeks of treatment, they measured the change in
blood pressure for each participant. The company wants to determine if there is a significant
difference in the mean reduction in blood pressure between the two drugs.

The data are as follows:

For Drug A: For Drug B:

Sample mean: 8 mmHg
Sample standard deviation: 2 mmHg • Sample mean: 6 mmHg
Sample size: 10 • Sample standard deviation: 3 mmHg
• Sample size: 10

SOLUTION:

Hypothesis:

H0: μ1 = μ2 (There is no significant difference in the mean reduction in blood pressure between the two
drugs)

H1: μ1 ≠ μ2 (There is a significant difference in the mean reduction in blood pressure between the two
drugs)

Calculate the test statistic t.

First, we will calculate the pooled SD

sp = √ (n1-1) s12 + (n2-1) s22 / (n1+n2-2)

= √ (10-1) *22 + (10-1) *32 / (10+10-2)

=2.5

Next, we will calculate the test statistic t:

t = (x1 – x2) / sp (√1/n1 + 1/n2)

= (72-70) / sp (√1/10 + 1/10)

= 1.75

degrees of freedom = n1+n2-2 = 10+10-2 = 18 is 2.101

conclusion

Since, our calculated value is less then table value we fail to reject the null hypothesis.

Interpret: The difference in means observed in the samples is not statistically significant at the chosen
significance level.

18. A group of researchers wanted to see if a new drug could reduce cholesterol levels in
patients. They measured the cholesterol levels in 15 individuals before they started the treatment
and again after completing the treatment. The goal was to find out if there was a significant
change in cholesterol levels. The differences (after - before) for each person are as follows:

-10 -5 -8 -12 -6 -9 -4 -7 -11 -3

-8 -10 -5 -7 -12

SOLUTION:
Hypothesis:

H0: μ1 = μ2 (This is the hypothesis that there is no significant difference between the means of the
paired groups.)

H1: μ1 ≠ μ2 (This is the hypothesis that there is a significant difference between the means of the
paired groups.)

Differences(d) Mean(d)= d d-𝑑̅ (d-𝑑̅ )2

 -10 -2.2 4.84
-5 2.8 7.84
-8 -0.2 0.04
-12 -4.2 17.64
-6 1.8 3.24
-9 -7.8 -1.2 1.44
-4 3.8 14.44
-7 0.8 0.64
-11 -3.2 10.24
-3 4.8 23.04
-8 -0.2 0.04
-10 -2.2 4.84
-5 2.8 7.84
-7 0.8 0.64
-12 -4.2 17.64
Total ∑(d-𝑑̅ )2=114.4

n=15
∑𝑑𝑖 −117
Mean (𝑑̅) = 𝑛 = 15 = -7.8
Variance (s2) = ∑(d-𝑑̅)2/n-1 = 114.4/14 = 8.17
SD √ s2 = √8.17 = 2.85

Calculate

𝑥𝑑𝑖𝑓𝑓 −7.8
𝑡= 𝑆𝑑𝑖𝑓𝑓 t= 2⋅85 t= -10.59
√𝑛 √15

Degree of freedom df= n-1 = 15-1 =14

t-table value = 1.761

Conclusion: Since our calculated value is less then t-table value we accept null hypothesis and
conclude that the observed change in cholesterol levels before and after the treatment is not
statistically significant at the chosen significance level.

19. In the prospective study of singleton births to mothers who conceived following IVFU (in-
vitro feralization) the following data were observed on hypertension during pregnancy and low
birth weight.
 Low birth< Normal birth Total
2500 gm weight 2500+ gms

Hypertension 27 (a) 62 (b) 89 (a+b)

No Hypertension 53 (c) 499 (d) 552 (c+d)

Total 80 (a+c) 561 (b+d) 641 (a+b+c+d)

Examine the relationship between hypertension during pregnancy and birth weight.

SOLUTION:

Hypothesis:
H0: There is no association between hypertension during pregnancy and birth weight.
H1: There is an association between hypertension during pregnancy and birth weight.
Calculating Proportions

Proportion (Low Birth Weight | Hypertension) =a/a+b = 30.33%

Proportion (Normal Birth Weight | Hypertension) = b/a+b= 69.66%
Proportion (Low Birth Weight | No Hypertension) =c/c+d= 9.60%
Proportion (Normal Birth Weight | No Hypertension) =d/c+d= 90.39%

2. Calculate expected frequencies:

Eij=N(Ri⋅ Cj)/N

E11= (80*89)/641=11.10

E12= (80*552)/641=68.89

E21= (561*89)/641=77.89

E22= (561*552)641=483.10

20. Calculate the chi – square value for each cell

Chi – square = ∑(O-E)2

Where ‘O’ is the observed frequency and

‘E’ is the expected frequency

 Observed Expected value (O-E)2 /E chi –
value (O) (E) square
Cell value

C1 27 11.10 (27-11.10)2/11.10 22.77

C2 62 68.89 (62-68.89)/68.89 0.68

C3 53 77.89 (53-77.89)/77.89 7.95

C4 499 483.10 (499-483.10)/483.10 0.52

Sum of Chi ∑(O-E)2 /E 31.85

square

Chi – square value = ∑(O-E)2 / E = 31.85

Degree of freedom = (r-1) x (c-1) = 1

Interpreting the chi – square test

Table value of chi – square at 5% level at 1 degree of freedom is 3.84. The calculated value of chi –
square is (31.85) more than the table value. Therefore, we reject the Null Hypothesis.

21. We have a trial of 2 whooping cough vaccines. The results of the field trial were as below

Vaccine Attacked Not Attacked Total

A 22 68 90
B 14 72 86
Total 36 140 176
Apparently, vaccine-B was superior to vaccine-A. The question that arises is whether the vaccine-B
was really superior to vaccine-A, or whether the difference is merely due to chance. Compute with the
chi-square test.
Solution:

• N1 =90 – no. of subjects who were given Vaccine A.

• a = 22 - subjects who were given Vaccine-A and those who attacked.
• b = 68 - subjects who were given Vaccine-A and those who not attacked.
 • N2 = 86 – no. of subjects who were given the Vaccine-B
• c = 14 - subjects who were given Vaccine-B and those who attacked.

• d = 72 - subjects who were given Vaccine-B and those who not attacked.

Hypothesis:

H0: There is no significant difference in the effectiveness of vaccine-A and vaccine-B in preventing
whooping cough.

H1: There is a significant difference in the effectiveness of vaccine-A and Vaccine-B is significantly
superior to vaccine-A in preventing whooping cough.

Part – I: Calculating Proportions

Proportion (Attacked | Vaccine-A) =(a/a+b) *100 =24.4 %

Proportion (Not Attacked | Vaccine-A) = (b/a+b) *100=75.5 %

Proportion (Attacked | Vaccine-B) =(c/c+d) *100=16.2 %

Proportion (Not Attacked | Vaccine-B) =(d/c+d) *100= 83.7%

Part – II: calculate the Expected frequency for each cell (E)

C1 = HT1 X VT1 / GT= (90 x 36) / 176 = 18.40 (E1)

C2 = HT1 X VT2 / GT = (90 x 140) / 176 = 71.59 (E2)

C3 = HT2 X VT1/ GT = (86 x 36) / 176 =17.59 (E3)

C4 = HT2 X VT2/ GT = (86 x 140) /176 = 68.40 (E4)

Part – III: Calculate the chi – square value for each cell

Chi – square = ∑(O-E)2 / E

Where ‘O’ is the observed frequency and

‘E’ is the expected frequency

 Observed Expected value (O-E)2 /E chi –
value (O) (E) square
Cell value

C1 22 18.40 (22-18.40)2/18.40 0.70

C2 68 71.59 (68-71.59)2/71.59 0.18

C3 14 17.59 (14-17.59)2/17.59 0.73

C4 72 68.40 (72-68.40)2/68.40 0.18

Sum of Chi ∑(O-E)2 /E 1.79

square

Chi – square value = ∑(O-E)2 / E = 31.85

Degree of freedom = (r-1) x (c-1) = 1

Interpreting the chi – square test

Table value of chi – square at 5% level at 1 degree of freedom is 3.84. The calculated value of chi –
square is (1.79) less than the table value. Therefore, we accept the Null Hypothesis.

Therefore, there is not enough evidence to suggest that vaccine-B is superior to vaccine-A in
preventing whooping cough.