Epidemiological Exercises

Part I

Presenter
Dr. Meghana Narendran
Assistant Professor
Department of Community Medicine
Symbiosis Medical College for Women,
Pune
 Plan of Presentation

• Epidemiological exercises on,

• Sensitivity and specificity

• Disinfection of well, swimming pool

• Vector indices – Malaria, filaria

2
 “
Introduction

3
4
 Screening
Definition
“ The search for unrecognized disease or defect by means of
rapidly applied tests, examinations or other procedures in
apparently healthy individuals.”

“The presumptive identification of unrecognized defect or disease

by the application of tests, examinations or procedures which can
be applied rapidly, to sort out apparently well persons who
probably have a disease, from those who probably do not.”

5
 “
Criteria for Screening

6
 Criteria for Screening

•Before initiating a screening programme, a decision must

be made whether it is ethically, scientifically and financially
justified.

•It is based on 2 considerations

1. DISEASE to be screened
2. TEST to be applied

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 Disease
1. It is of public health importance.
2. It has recognizable latent or early asymptomatic stage.
3. The natural history of the condition, including development
from latent to apparent disease, is adequately understood.
4. There is a test that can detect the disease prior to the onset of
signs and symptoms.
5. There are facilities available for confirmation of diagnosis.
6. There is an effective treatment.
7. There is an agreed policy regarding whom to treat as patients.
8. There is good evidence that early detection and treatment reduces
morbidity and mortality.
9. The expected benefits of early detection exceed the risks and
costs.

For Example: Breast Cancer, Cervical Cancer

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 Screening Test
1. Acceptable

2. Repeatable

3. Valid

4. Yield

5. Simple, Safe, Cheap and Rapidly applied

 The test should be simple to perform, easy to

interpret and, where possible, capable of use by
paramedics and other personnel.
Example: Capillary Blood glucose and urine tests
9
 Acceptability

• Since participation in screening is voluntary, the

test must be acceptable to those undergoing it.

• In general, tests that are painful, discomforting

or embarrassing are not likely to be acceptable.

Example: Screening for prostrate cancer might not

be acceptable to a large proportion of the
community.

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 Reliability
≈ Repeatability, Reproducibility, Precision

“It is the ability of the test to give consistent results when

repeated applications are made.”

Depends on three major factors

1. Observer variation,
2. Biological variation, and
3. Mechanical variation

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 Observer Variation:

Intra-observer variation:
Variation between repeated observations by
the same observer on the same subject or material at
the same time.
≈ within-observer variation.
Example: Blood pressure measurement.

Inter-observer variation:
Variation between different observers on the
same subject or material.
≈ between-observer variation
Example: X-Ray film report by different
radiologist

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 Kappa Statistic
•Type of inter-observer agreement.
•Takes into account agreement between two observers
purely by chance.
•It is defined as the extent to which inter-observer
agreement exceeds the agreement that is purely by
chance.

> 0.75= Excellent Agreement Beyond Chance

0.40-0.75 = Intermediate to Good Agreement
< 0.40 = Poor Agreement

Kappa= (Percent agreement observed) – ( Percent agreement expected by chance alone)

100% - (Percent agreement expected by chance alone)

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Biological Variation
≈Intra-subject variation
Variation associated with many physiological variables like
blood pressure, blood glucose, etc.

Biological Variation of Human Populations

Bimodal Curve Uni-modal Curve

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Mechanical Variation

•These are errors relating to technical methods.

•Repeatability may be affected by variations inherent in the

method.

•Example:
Defective instruments
Erroneous calibration
Faulty reagents
Inappropriate/ Unreliable test

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Reliability can be ensured by:

Standardization of definitions of the disease.

Using standard techniques for measurement.

Using standardized instruments.

Training of workers.

Continued supervision

Establishing a quality control system.

Using good quality instruments and reagents.

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 Validity
“Validity is the ability of the test to correctly diagnose what
it intends to diagnose.”

Validity is interpreted in terms of

* Sensitivity
* Specificity
* Positive Predictive Value
* Negative Predictive Value

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 S S
E P
a b
N E
S C
POSITIVE PREDICTIVE VALUE
I I
T F
I I
V C
c I d I
T T
NEGATIVE PREDICTIVE VALUEY Y

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 Sensitivity and Specificity:
•Sensitivity:
It is the ability of a test to identify correctly all those who have
the disease, i.e. True Positive

•Specificity:
It is the ability of a test to identify correctly those who do not
have the disease, i.e. True Negative

True Characteristic in the population

Test Result Have the Disease Do not have the Disease
True Positive False Positive
Positive Have the disease and test positive Do not have the disease but test positive

False Negative True Negative

Negative Have the disease but test negative Do not have the disease and test negative

Sensitivity = TP Specificity = TN___

TP+FN TN+ FP
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20
Concept of Cut-Off

If the diagnostic test is expensive or invasive:

- minimize false positives
- use a cut-point with high specificity

If the disease is fatal and treatment exists, or disease

easily spreads:
- maximize true positives, minimize false negatives
- use a cut-point with high sensitivity

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Predictive values

Positive predictive value

The proportion of patients who test positive, actually
have the disease in question.

Negative predictive Value

The proportion of patients who test negative,
actually do not have the disease in question.

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Limitations of Predictive Values

•The positive predictive value is directly related to the

prevalence of the disease.

•Similarly, the negative predictive value is inversely related

to the prevalence.

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Epidemiological
Exercises
 Question 1
A rapid test for streptococcal pharyngitis was tested on 400
individuals who have culture proven streptococcal
pharyngitis and 400 others who were suffering from other
febrile illnesses. There were 320 test positive, but 25 of
them were false positive.

a. Calculate sensitivity
b. Calculate specificity
c. Calculate PPV
d. Calculate NPV

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 Streptococcal Pharyngitis
New Test
Total
Yes S No S
E P
Yes N E
295 25 320
S VALUE
POSITIVE PREDICTIVE C
a b a+b
I I
No 105 T 375 F 480
c I VALUE
NEGATIVE PREDICTIVE d I c+d
Total 400 V 400 C 800
I I
a+c T b+d T
Ans: Y Y

◎Sensitivity: a/a+c = 295/400 * 100 = 73.75%

◎Specificity: d/c+d = 375/400 * 100 = 93.75%
◎PPV: a/a+b = 295/320 * 100 = 92.18%
◎NPV: d/c+d = 375/480 * 100 = 72.12%

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 Question 2
A group of migrants with a history of unprotected sex were
subjected to HIV testing using Western Blot and a new
testing. Out of the 360 migrants, 110 were positive for
Western blot. Out of this 110, only 60 were positive for the
new test. Among the remaining who showed negative for
Western Blot, 104 were positive with the new test.

a. Calculate sensitivity
b. Calculate specificity
c. Calculate PPV
d. Calculate NPV
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New Test HIV ( Western Blot ) Total
Yes No

Yes 60 104 164

No 50 146 196

Total 110 250 360

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 Question 3
A programme for screening of DM was done in Hadinaru
village. Totally 500 people were screened. Based on blood
sugar measurement by digital glucometer, 120 people were
found to be positive. On further investigations by glucose
oxidase peroxidase method, 100 were diabetic of which
glucometer had detected 90 cases correctly.

a. Calculate sensitivity
b. Calculate specificity
c. Calculate PPV
d. Calculate NPV of digital glucometer .

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Test Positive Negative Total
Positive 90 30 120

Negative 10 370 380

Total 100 400 500

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 Question 4
A study was conducted during 2015 at a private medical
college of Venjaramoodu to determine utility of FNAC for
IDD. 1500 individuals with enlarged thyroid were subjected
to FNAC and biopsy examination, of which 450 cases were
positive for both examination whereas 90 more cases were
detected by biopsy examination. The FNAC positive for IDD
was 680.
a.Calculate sensitivity
b.Calculate specificity
c.Calculate PPV
d.Calculate NPV

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FNAC BIOPSY
Total
Yes No
Yes 450 230 680
No 90 730 820
Total 540 960 1500

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 Question 5
A new Screening test for a disease was administered to 520
patients, 70 of whom are known to have the disease. The
test was positive in 55 persons with the disease and 25
persons without the disease. Construct a 2x 2 table.

a. Calculate sensitivity
b. Calculate specificity
c. Calculate PPV
d. Calculate NPV
e. prevalence of disease.

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 Disease
Screening Present Absent Total
test
Positive 55 25 80
Negative 15 425 440
Total 70 450 520

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 Question 6
Pap smear test was being evaluated for cervical cancer.
This test was done for 480 females, 60 of whom were
known to have the disease. This test was found to be
positive in 50 of the 60 females with disease as well as 150
female who didn’t have the disease. Calculate following
parameters:

a. Calculate Sensitivity
b. Specificity
c. Positive predictive value
d. Negative predictive value
e. Percentage of false positive cases
f. Percentage of false negative cases
g. Prevalence of the disease. 35
 Disease

Test Present Absent Total

Positive 50 (a) 150 (b) FP 200
Negative 10 (c) FN 270(d) 280
Total 60 420 480

g. Prevalence = Number of people having the disease x 1000

Total No of people

60 x 1000 = 125 / 1000 population

480

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 To be written in the Record books
•Introduction - Definition
• Uses of Screening
• Types of Screening
•Difference b/w Screening & diagnostic test
• Criteria for Screening
• Evaluation of Screening Tests
•Evaluation of Screening Programmes
•Epidemiological exercises – 6 Question & answers

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Disinfection of well

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Disinfection of well

Water supply in rural areas

Disinfection is must during epidemics
(cholera & GE)
Most effective & cheapest method is
bleaching powder

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Steps in well disinfection

Find the volume of water in the well

Measure the depth of water column (h in
meters)
Measure the diameter of well (d in meters)
Volume in liters = 3.14*d2*h*1000
4
1cu.m=1000 lit of water

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Steps in well disinfection…..
Find the amount of bleaching powder
required for disinfection
Estimate the chlorine demand with Horrock's
apparatus
Calculate the amount of bleaching powder
required
2.5gm/1000 lit. of water after estimating
0.7mg of chlorine /1 lit. of water

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Steps in well disinfection…..
Dissolve bleaching powder in water
Not more than 100gm. In a bucket of water
made into thin paste
Water is added till the bucket is 3/4th full
Stir well and allow to sediment for 5-10min
Lime settles down
Supernatant solution is chlorine solution

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Steps in well disinfection…..
Delivery of chlorine solution into well
Contact period for 1hr.
Ortho-tolidine arsenite test for estimating
residual chlorine at the end of 1hr. contact
time
If the residual chlorine is <0.5mg/lit repeat
chlorination
Preferable to do at night time
During epidemics disinfect every day

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Double pot method

To ensure constant dosage of chlorine to

well water during emergency
Evolved by NEERI-Nagpur
This devise works satisfactorily for 2-3
weeks in a small household wells containing
about 4500 lit. of water and having a draw off
rate of 360-450 lit./day
1kg.of bleaching powder & 2kg.of coarse
sand slightly moistened with water

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Disinfection of Wells during an Emergency –
The Double Pot Method:
E.g. an outbreak of cholera.

• During an emergency, it is desirable to ensure a constant

dosage of chlorine to well water.

• One method of doing this is the ‘Double pot method’

• The method is an improvement devised by the National

Environmental Engineering Research Institute (NEERI),
Nagpur, India
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There are two cylindrical pots
• One pot is placed inside the other
• Outer pot:
Inside height is 30 cm
Inside diameter is 25 cm
A hole (1 cm diameter) is made at 4 cm above
the bottom
• Inside pot:
Fits into the outer pot
Has a hole (1 cm diameter) near the upper end

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A mixture of 1 Kg bleaching powder and 2 Kg sand is prepared and
moistened with some water
• The inner pot is filled with this mixture up to 3 cm below the hole
• The inner pot is placed into the outer one
• The mouth of the latter is closed with polyethylene foil
• The double pot is lowered into the well by means of a rope attached to
the well kerb
• The pot should be immersed at least 1 m below the water level to
prevent damage by the buckets used for drawing water
• This device works satisfactorily for 2 – 3 weeks in small household
wells containing 4500 L of water and a draw off rate of 360 to 450 L per
day 47
Exercises

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 Exercises – Q 1

A circular well of 10 meter diameter with 15 meter

depth of water is to be chlorinated. Horrock’s test shows
blue colour in 3rd cup onwards.

a) Calculate the quantity of bleaching powder

(CaOCL2) required to disinfect the well.

b) Explain the procedure of well disinfection.

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 Step 1: Finding the volume of well water
Volume of water in the circular well = π r² h x 1000

Π = 22/7 = 3.14
r = radius = 5 mt ( half of diameter)
h = height = 15 mt water column
1000 = volume of water per 1 m cube
= π r² h x 1000
= 3.14 x 5 x 5 x15 x 1000 = 1,77,500
Volume of water in the well is = 1,77,500

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 Step 2: Finding the amount of bleaching powder
requirement
◎3rd cup is the earliest cup showing blue colour
◎3rd cup means – 3 level spoon(3x2gms) = 6 gm of
bleaching powder is required to disinfect 455 lit of
water.
◎455 lit of water requires = 6 gm of bleaching
powder,
◎For 1177500 lit = ????
◎= 6/455 x 1177500 = 15,527.5 gm (roughly 15.5 kg)
◎Therefore, 15 kg and 527 gm of bleaching powder is
required to disinfect the well water.
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 Exercise – Q 2

A swimming pool having 100 mt length, 60 mt breadth,

with 10 mt depth of water is to be disinfected.

a) Calculate the amount of bleaching powder required to

disinfect the swimming pool. Horrocks apparatus shows
blue colour in 4th cup.

b) What measures you advice for swimming pool

sanitation.
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55
Exercise – Q 3

A circular well of 14 meter diameter with 20 meter

depth of water is to be chlorinated. Horrock’s test
shows blue colour in 5th cup onwards.

a) Calculate the quantity of bleaching powder

(CaOCL2) required to disinfect the well.

b) Explain the procedure of well disinfection

during epidemics. (Double pot method)
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To be written in logbook

◎Safe and wholesome water

◎Water sources
◎Water pollution – natural and man-made
◎Purification of water – Draw neat labelled
diagram of Slow and Rapid sand filter. Write steps
of filtration.
◎Exercises
◎Homework: Read about – Rain water harvesting,
Water Law.

57
 “
Vector Indices
Malaria and (API, AFI, ABER,
SPR, SFR) Filarial indices,
control measures

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Learning Objective:

◎ To assess the burden of disease in a community in

terms of morbidity and mortality wrt malaria, filarial

◎ To calculate indices to monitor and evaluate

national health program wrt malaria and filaria

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 Vector Indices

Q 1. During the year 2022, Maale PHC covering

30,000 population had collected 4,000 PBS by
house to house visit. Another 400 slides were
collected in the OPD. Results of microscopic
examination of these slides are gives to you:

Pl. vivax Positive 41

Pl. falciparum Positive 9
Total 50 Positive.

Calculate the possible malarial indices and suggest

the remedial measures in brief.
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Malarial parameters:
Annual parasite Incidence(API)= confirmed cases in
one year / population under surveillance X 1000
= 50 / 30,000 x 1000
= 1.6 per thousand population.

Annual falciparum incidence(AFI) = number of

cases due to falciparum / Population under
surveillance X 1000
= 9 / 30000 x 1000
= 0.3 per thousand population.

Annual blood examination rate(ABER) = number of

slides examined / Population under surveillance x 100
= 4400 / 30000 x 100
= 14.6 %
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Slide positivity rate(SPR) = number of slides positive
for malaria / Number of slides examined X 100
= 50 / 4400 x 100
= 1.13%

Slide falciparum rate(SFR) = number of slides

positive for p.falciparum / Number of slides examined
X 100

= 9 / 4400 x 100
= 0.20%

Percentage of falciparum = No. of slides showing

falciparum / Total no. of slides showing parasite X 100

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Control measures:

- Maale PHC can be classified as an area with API less

than 2.
- According to modified plan of operation(MPO) measures
required are:
- Focal spraying in and around p.falciparum detected
houses.
- Active and passive surveillance(once in 15 days).
- Mass blood survey of people living around patients
home.
- Treatment: Prompt Rx is given to all detected cases.
- Follow-up: After completion of radical Rx, monthly blood
examination should be carried out for 12 months.
- Epidemiological investigation: All positive cases are to
be investigated.
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Q 2. In the year, 2021, API of a tribal district was
3/1000. Falciparum malaria cases had been
reported with 10 deaths. How will you strengthen
the surveillance and containment of malaria in that
area?
◎Early diagnosis and treatment
◎Case based surveillance and rapid response
◎Integrated vector management
- Indoor residual spraying
- Long lasting insecticidal nets/insecticide treated bed
nets
- Larval source management
o Epidemic preparedness and early responses
o Monitoring and evaluation
o Advocacy, coordination and partnerships
o Behaviour change communication and community
mobilization.
o Programme planning and management. 64
◎Usually malaria surveillance is done by:
◎ACF
◎PCF
◎Rapid fever survey
◎Mass fever survey

◎Active Case Finding:

◎Carried out by multipurpose health workers in PHC
◎Every fortnight periodicity of house to house visit
◎Fortnight visits are done to catch most secondary
cases
◎Search for all fever cases
◎If cases have fever,- collect blood films(thick and thin
on same slide)
◎If cases are positive for malaria, radical treatment is
provided.
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◎Passive Case Finding:
◎All fever cases attending hospitals are screened for
malaria and treated accordingly.
◎Medical officer with the help of PHC staff should
carry out mapping of private clinics, under guidance of
DMO.
◎Various malaria clinics are to be established in all
health institutions in high risk areas.
◎MPHW male should contact all fever treatment
dispensaries for drug replacement (fortnightly).

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◎Rapid fever survey:
◎House to house visits are undertaken and all fever
cases screened by blood smears.
◎Blood smears are to be examined at earliest in the
temporary field lab at village level

◎Mass survey:
◎Carried out for entire population in suspected
epidemic zone.

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◎As It is high risk area API > 2:
1. Vector control:
- Indoor residual spray
- Use of chemical larvicides like Abate in potable
water
- Aerosol spray during day time
- Marathon fogging during outbreaks
- Biologically by – larvivorous fish in ornamental
tanks and fountains
- Personal protective measures – bed nets, mosquito
repellents
2. Increased community participation:
3. Environmental management by source reduction
4.Entomological assessment–to carryout susceptibility
tests and suggest required insecticide
5. Health education.
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Q 3: A routine clinical survey for filariasis was
carried out in a community health centre, serving 1
lakh population, data collected is as follows:

◎Night blood smears collected 30000

◎Persons showing only mf positive 300
◎Persons showing signs of filariasis 80
◎Persons showing both mf positive and signs 10

Calculate the possible filarial indices and suggest the

control measures.

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Sample size: For routine filarial survey, sample size
recommended is 5 to 7%. In this survey, 30% sample
is examined, hence the sample is adequate and
acceptable.

Filarial indices:
◎Microfilarial rate (mf) = number showing mf
positivity / Number of persons(slides) examined X 100
= 300 / 30000 x 100
= 1%
Filarial disease rate = Number showing filarial
disease symptoms / Number of persons examined X
100
= 80 / 30000 X 100
= 0.26%
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◎Filarial endemicity rate = signs + number of mf
positives + Both / Number of persons examined X 100
= 80+300+10 / 30000 X 100
= 1.3%

Control measures:
o Against the parasite
o Mass chemotherapy
o - Given to all in endemic area
o Given only for cases and carriers in low endmic
areas
o Drug – Diethylcarbamazine(DEC) (Hetrazan)
o Dose – 6mg/Kg/day divided doses after meal
o Duration – 6 days in a week for 2 weeks, i.e. 12
days
o Total dose: 72 mg/Kg
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◎Medicated salt:
◎- Common salt medicated with 1-4 gm of DEC/Kg
◎Recent Schedule:
◎- DEC
◎Or Invernectin
◎Or combination of both
◎Plus, Albendazole as a supplement
◎0.1% DEC mixed salt and distributed to all

◎Vector Control
◎Antiviral measures:
◎- Chemical application of selected insecticides once
in a week on all breeding places
◎Mosquitoes larvicidal oil (MLO)
◎Fenthion 1ppm
◎Organophosphorus – Temephos, fenthion
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◎Anti-adult measures:
◎- Pyrethrum space spray / insecticidal spray in and
around
◎Open underground sewage system
◎Neighbourhood at human dwelling
◎Environmental measures:
◎- Source reduction
◎Integrated vector control
◎Personal prophylaxis
◎Other measures:
◎- Maintenance of local hygiene of affected
organ(Leg)
◎- Primary health care approach
◎Periodic night blood examination
◎Blood examination: by taking capillary blood by deep
finger prick between 8.30 to 12 mid night
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◎Health education: Dynamic health education,
campaign is organised to motivate the people, to
cooperate in anti-filarial activities and to take complete
treatment.
◎Surveillance

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 Home work

1. In a community health centre, with a population of

1,00,000, the health workers collected 3725 blood
smears from fever cases during their home visits. In
the same year, 3275 blood smears were collected
from OP. On examination, 185 slides were positive for
p.vivax and 15 slides were positive for p.falciparum.
Calculate the all malarial indices.

75
2. Population of a PHC is 25000. A total of 200 PBS
were collected. About 38 were tested positive for
p.vivax, 40 for p.falciparum and 10 showed both.
Calculate indices for malaria control in the area.
Interpret and comment on remedial measures.

76
 Chandler’s index

Average no. of eggs per gram of stool

◎Below 200 – Hookworm infection is not significant

◎200 -250 = Potential danger
◎250 – 300 = Minor public health problem
◎Above 300 = Important public health problem

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 Flea (Xenopsylla cheopis) Indices

Flea indices are useful measurements of the density

of fleas. They are also useful in evaluating the
effectiveness of a spraying programme. The following
flea indices are widely used in rat flea surveys :
(a) TOTAL FLEA INDEX : It is the average number of
fleas of all species per rat.
(b) CHEOPIS INDEX: It is the average number of X.
cheopis per rat. It is a specific flea index. It is a more
significant index than the total flea index.
If this index is more than 'one', it is regarded as
indicative of potential explosiveness of the situation,
should a plague outbreak occur.
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(c) SPECIFIC PERCENTAGE OF FLEAS : It is the
percentage of different species of fleas that are found
on rats.
(d) BURROW INDEX : It is the average number of
free- living fleas per species per rodent burrow.

Flea indices do not in themselves indicate an

imminent plague epidemic. They serve as a warning
that more stringent control measures are needed to
protect the human population.

79
Thank you