Epidemiology

Approach and Methods

 Data Sources and Collection Methods
Source Method Example

Individual persons • Questionnaire • Foodborne illness outbreak

• Survey • National Health and Nutrition Examination
Survey
• Demographic Health Survey

Environment • Samples from the environment • Collection of water from area streams —
(river water, soil) check for chemical pollutants
• Sensors for environmental changes • Air-quality ratings

Health care providers • Notifications to health department • Report cases of meningitis to health
if cases of certain diseases are department
observed

Nonhealth–related sources • Sales records • Cigarette sales

(financial, legal) • Court records • Intoxicated driver arrests
 Epidemiology Study Types

Experimental
Epidemiology
study Descriptive
types
Observational

Analytic

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 Descriptive and Analytic
Epidemiology
Descriptive Analytic
epidemiology epidemiology

When was the How was the

population affected? population affected?

Where was the population Why was the

affected? population affected?

Who was affected?

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Descriptive observations pertain to the “who,
what, where and when of health-related state
occurrence”. However, analytical observations deal
more with the ‘how’ of a health-related event
occur.

Randomized control trial (often used for new

medicine or drug testing), field trial (conducted on
those at a high risk of contracting a disease), and
community trial (research on socially originating
diseases)
Steps in Conducting a Descriptive Study.
Descriptive studies are concerned with observing the
distribution of disease in populations. Therefore;
1. Defining the population.
2. Defining disease under study.
3. Describing the disease.
4. Measurement of disease
5. Compare
6. Formulate hypothesis
1. Defining the Population.

Defined population may be the whole population

or a representative sample.
It can also be specially selected group such as
age and sex groups, occupational groups, hospital
patients, school children, small community, etc.
2. Defining disease under study.
3. Describing the disease.
Disease is examined by epidemiologists by asking
three questions:
● When is the disease occurring—time distribution?
● Where is it occurring—place distribution?
● Who is getting the disease—person distribution?
4. Measurement of disease - Mortality/Morbidity

5. Compare - Between different population,

subgroups

6. Formulate hypothesis. On basis of all data

epidemiologist form hypothesis.
 Cross-Sectional Study
Subjects are selected because they are members of a
certain population subset at a certain time
Cross-sectional Studies: also known as "prevalence study"
Cross-sectional study is the simplest form of an observational
study.
It is based on a single examination of a cross-section of
population at one point in time
 The results can be projected on the whole population,
provided, the sampling has been done correctly.
 Cross-Sectional Study
Cross-sectional studies save on time and
resources, but provide very little
information about natural history of
disease and incidence of illness
 Longitudinal Studies
Observations are repeated in the same population over a
prolonged period of time by means of follow-up
examinations.
Longitudinal studies are useful for
Studying the natural history of disease and its future
outcome
Identifying risk factors of disease, and
Finding out incidence rate or rate of occurrence of new
cases of disease in the community.
 Other Study Designs
Case control
• Compare a group of individuals with disease (“case” group)
and a group (“control” group) without disease with respect to
the factor of interest (exposure/treatment)
• Retrospective or prospective
Cohort
• A sample of a reference population is examined at a given
point in time
• A “cohort” is defined and individuals are classified as to
exposure levels
• Study participants are followed over time and assessed for
the development of disease
Experimental
 Case - Control Studies
They start from effect and then proceed to cause
Both exposure and outcome have occurred before
start of the study
The study proceeds backwards from effect to cause
(RETROSPECTIVE)
Select subjects based on their disease status.
A group of individuals that are disease
positive (the "case" group) is compared with a
group of disease negative individuals (the
"control" group).
The control group should ideally come from
the same population that gave rise to the
cases.
Basic steps in a case-control study
1. Selection of cases and controls
2. Matching
3. Measurement of exposure
4. Analysis and interpretation.
A 2×2 table is constructed, displaying exposed cases (A),
exposed controls (B), unexposed cases (C) and unexposed
controls (D).
CASE CONTROLS
EXPOSED A B
UNEXPOSED C D

To measure association is the odds ratio (OR), which is the

ratio of the odds of exposure in the cases (A/C) to the odds of
exposure in the controls (B/D), i.e.
OR = (AD/BC).
 Case with lung Control without
cancer lung cancer
Smokers (less 33 (a) 55 (b)
than 5 )
Non-Smokers 2 (c) 27 (d)
(less than 5 )

The first step is to find out

1. Exposure rates among cases
=a/(ac) = 33/35 =94.2%
2. Exposure rate among the controls
=b/(bd) = 55/82 =67%
 If the exposure rate among the cases is
more than the controls.
We must see if the exposure rate among the
cases is significantly more than the controls.
This is done by using the chi-square test
It is significant if p is less than 0.05.
 Odds Ratio

It is a measure of strength of association between the risk

factor and outcome.
The derivation of the odds ratio is based on three assumptions:
● The disease being investigated is relatively rare
● The cases must be representative of those with the disease
● The controls must be representative of those without the
disease.
Odds ratio a.d/b.c
33X27/55X2 = 8.1
People who smoke less than 5 cigarettes per day showed a risk of
having lung cancer 8.1 times higher as compared to non-smokers.
 OR is > 1- "those with the disease are more likely to
have been exposed,"
OR close to 1 then the exposure and disease are not
likely associated.
OR <1-exposure is a protective factor in the
causation of the disease.
Case control studies are usually faster and more cost
effective
Sensitive to bias (selection bias).
The main challenge is to identify the appropriate control
group;
The distribution of exposure among the control group
should be representative of the distribution in the
population that gave rise to the cases.
 Cohort Study
It looks at cause and proceed to effect
Study before the disease is manifest and proceed to study
over a period of time for the disease to occur.
Cohort means a group of people sharing a common
experience.
Cohort studies are often prospective studies, they can be
retrospective also, or a combination of both prospective
and retrospective components can be brought in.
Steps in a cohort study:
1. Selection of study subjects
2. Obtaining data on exposure
3. Selection of comparison groups
4. Follow-up
5. Analysis.
 CHD Develops CHD does not total
develop
Smoker 84 (a) 2916 (b) 3000 (a+b)

Non-smoker 87 (c) 4913 (d) 5000 (c+d)

Total 171 (a+c) 7829 (b+d) 8000

The incidence rates of CHD among smokers i.e. a/(a+b)

=84/3000 =28 per 1000

The incidence rates of CHD among non-smokers i.e.

=c/(c+d)
=87/5000 =17.4 per 1000
Then, we must determine if the incidence rate
among the smokers is significantly more than
among the non-smokers by using the chi-
square test.
 Relative Risk (RR)
It is ratio of incidence of the disease among the exposed and
incidence among the non-exposed.
RR (incidence of disease among exposed)/
(Incidence of disease among non-exposed)
=a/(ab)/c/(cd)
=28/17.4
=1.6
If RR is more than 1, then there is a positive association
If RR is equal to 1, then there is no association
Smokers develop CHD 1.6 times more than nonsmokers.
 Attributable Risk (AR)
This is defined as amount or proportion of disease incidence that can
be attributed to a specific exposure.
It indicates to what extent the disease under study can be
attributed to the exposure:
(incidence of disease among exposed)
- (incidence of disease among non exposed)/
(Incidence of disease among exposed)
=28-17.4/28
= 10.6/28 = 0.379 = 37.9%
37. 9% of CHD among the smokers was due to smoking.
 Randomized Control Studies

Essential elements are:

Drawing up a strict protocol,
Selecting reference and
Experimental populations,
Randomization,
Intervention,
Follow-up
Assessment of outcome.
Randomization is a statistical procedure where
participants are allocated into groups called study
and control groups to receive or not to receive an
experimental therapeutic or preventive
procedure, intervention.
Randomization is an attempt to avoid bias and
allow comparability.
Study designs include
Concurrent parallel
Crossover type of study designs.
In the former, study and control groups will be
studied parallel whereas in the latter all the
participants will have the benefit of treatment
after a particular period because the control
group becomes study group.
Types of randomized control studies are:
Clinical trials, e.g. drug trials
Preventive trials, e.g. trials of vaccines
Risk factor trials, e.g. trials of risk factors of
cardiovascular disease, e.g. tobacco use, physical activity,
diet, etc.
Cessation experiments, e.g. smoking cessation experiments
for studying lung cancer.
 What is bias?
Bias is systematic error that comes in.
Bias on the part of participants if they know they belong
to study group—participant bias
Bias because of observer if he knows that he is dealing
with study group—observer bias
Bias because of investigator investigator bias, if he
knows he is dealing with study group.
In order to prevent this, a technique called blinding is
adopted.
 Concept of Blinding
Single blind trial means participant will not know
whether he belongs to study group or control group.
In double blind studies, both the participant and
the observer will not be aware.
In triple blind study, the participant, observer as
well as the investigator will not be aware
 A Public Health Approach

Risk Factor Intervention

Surveillance Identification Evaluation Implementation
 Solving Health Problems
Step 1 -

Step 1 Step 1 -
Data Surveillance; determine time,
collection place, and person

Step 2 Step 2
Assessment Inference
Solving health
problems
Step 3 Step 3
Hypothesis
Determine how and why
testing

Step 4 Step 4
Action Intervention
Action 40
Investigating an Outbreak

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 Outbreak Investigation
Ten steps are involved in outbreak investigations:
1. Establishing the existence of an outbreak
2. Preparing for fieldwork
3. Verifying the diagnosis
4. Defining and identifying cases
5. Using descriptive epidemiology
6. Developing hypotheses
7. Evaluating the hypotheses
8. Refining the hypotheses
9. Implementing control and prevention measures
10.Communicating findings
Outbreak Investigation — Steps 1 and 2

Step 1 — Establishing the

existence of an outbreak
• Use data from data sources

Step 2 — Preparing for field work

• Research the disease

• Gather supplies and
equipment
• Arrange travel
Outbreak Investigation — Steps 3 and 4

Step 3 — Verifying the

diagnosis
• Speak with patients
• Review laboratory findings
and clinical test results

Step 4 — Defining and

identifying cases
• Establish a case definition
by using a standard set of
criteria
Outbreak Investigation — Step 5

Step 5 — Using descriptive

epidemiology
• Describe and orient
the data
Outbreak Investigation — Steps 6, 7, and 8

Step 6 — Develop a focused

hypothesis
Step 7 — Evaluate the
hypothesis for validity
Step 8 — Refine the
hypothesis as needed
Legionnaires’ Disease Study Results

Five months after the first cases

of Legionnaires’ disease
occurred, results of the case-
control study indicated that
spending time in the lobby of
Hotel A was a risk factor for
illness
Legionnaires’ Disease Study Results

In December 1976, a CDC

laboratorian successfully located
the source bacteria after
continuing to test the specimens
that were thought to be dead
Outbreak Investigation — Steps 9 and 10
Step 9 — Implement control and
prevention measures
• Control and prevent additional cases

Step 10 — Communicate findings

• Determine who needs to know
• Determine how information will be
communicated
• Identify why the information needs
to be communicated