EPIDEMIOLOGY BASICS

 Dr ANKITA
 PG Resident
 Community medicine
Classically speaking

 Epi = upon (among)

 Demos = people
 Ology = science
 Epidemiology = the science which deals with what
falls upon people…..
 A Modern Definition


“The study of the distribution and
determinants of health-related states in
specified populations, and the application of
this study to control health problems."
(Last J)

Search for knowledge Apply in health service

 Objectives of Epidemiology

1. To describe the distribution and magnitude of health

and disease problems in the population.
2. To identify the etiological factors – risk factors in the
population.
3. To provide the data essential to planning,
implementation and evaluation of services for
prevention, control and treatment of disease and to
setting up of priorities for these services.
The aim of epidemiology is
 to eliminate or reduce health problem or
its consequences
and
 to promote health and well-being of
society as a whole.
 Purposes of Epidemiology

1. To investigate nature / extent of health-related

phenomenon in the community / identify priorities
2. To study natural history and prognosis of health-
related problems
3. To identify causes and risk factors
4. To recommend / assist in application of / evaluate
best interventions (preventive and therapeutic
measures)
5. To provide foundation for public policy
 Component:
Disease Frequency- Rate and ratio.
rate- incidence rate, prevalence rate etc
ratio- sex ratio, doctor-population ratio
Distribution of disease-
Disease in community find causative factor

generate hypothesis

descriptive epidemiology
Determinants of Disease-
to test hypothesis

analytic epidemiology

help to develop sound scientific program

 Incidence

 Number of new cases of a disease which come into being during

a specified period of time.
(Number of new cases of specific disease during a given
period)/(population at risk during that period) x 1000

Importance: if incidence increasing, it may indicate failure or

ineffectiveness of control measure of a disease and need for
better/new health control measure.
 Prevalence
 Number of current case (old and new) of a
specified disease at a point of time
 It help to estimate the burden of disease
 Identify potentially high-risk populations. They
are essentially helpful to plan rehabilitation
facilities, manpower needs, etc.
(Number of current case of a specified disease at a
point of time)/(estimated population at the same
point of time) x 100
 Point prevalence AND Period prevalence
Relationship between
incidence and prevalence

 Prevalence =Incidence x Duration

 Approach of an epidemiologist

 Asking questions
 making comparisons

● Asking questions may provide clues to cause or

aetiology of disease e.g.
What is the event,
what is its magnitude,
where did it happen,
when did it happen,
who were affected,
why did it happen?
 Making comparisons will help draw
inferences to support asking
questions.
 This comparison may be:
● Between those with the disease and
those without the disease;
● Those with risk factor and those not
exposed to risk factor;
Terms to know
 Endemic: constant presence of a
disease in a given population
 Epidemic: outbreak or
occurrence of one specific disease
from a single source, in a group
population, community, or
geographical area, in excess of
the usual level of expectancy
 Pandemic: epidemic that is
widespread across a country, or
large population, possible
worldwide
Epidemiology versus clinical medicine

Epidemiology Clinical medicine

 Unit of study is a defined  Unit of study is case

population or population
at risk
 Concerned with sick as  Concerned with only
well as healthy sick
 Investigator goes to the  Patient comes to doctor
community
 Seeks diagnosis, derives
 identify source of
infection, mode of prognosis, prescribes
spread, an Etiological specific treatment
factor, future trend or
recommend control
measures
Three essential characteristics
that are examined to study the
cause(s) for disease in analytic
epidemiology are...

 Host
 Agent
 Environment
 Host Factors

 Behaviors
 Genetic predisposition
 Immunologic factors

• Influence the chance for disease or its severity

 Agents

 Biological
 Physical
 Chemical

• Necessary for disease to occur

 Environment

 External conditions

• Contribute to the disease process

 Epidemics arise when host,
agent, and environmental
factors are not in balance

 Due to new agent

 Due to change in existing agent (infectivity,
pathogenicity, virulence)
 Due to change in number of susceptible in the
population
 Due to environmental changes that affect transmission
of the agent or growth of the agent
EPIDEMIOLOGICAL METHODS

The methods can be classified as:

1. Observational studies
a. Descriptive studies
b. Analytical studies
– Case control studies
– Cohort studies
2. Experimental/interventional studies
– Randomized control studies
– Field trials
– Community trials
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
conducting a disease), and
community trial (research on
social originating diseases)
Descriptive Studies
Steps in conducting a descriptive study.
Descriptive studies form the first step in
any process of investigation.
These studies are concerned with
observing the distribution of disease in
populations.
1. Defining the population.
2. Defining disease under study.
3. Describing the disease.
4. Measurement of disease
5. Compare
6. Formulate hypothesis-
Defining the population. Defined
population may be the whole
population or a representative sample.
 Itcan also be specially selected group
such as age and sex groups,
occupational groups, hospital patients,
school children, small community,
batch of vaccines, or medicines etc.
2. Defining disease under study.
3. Describing the disease.
Disease is examined by the epidemiologist
by asking three questions:
● When is the disease occurring—time
distribution?
● Where is it occurring—place distribution?
● Who is getting the disease—person
distribution?
A. Time Distribution
 Short-term fluctuations.
a. Common source epidemics –
1. Single exposure/point source e.g., epidemic of
food poisoning, Bhopal tragedy ,
Minamata disease in Japan.
2. Continuous and repeated exposure e.g., a well
of contaminated water,
b. Propagated- person to person transmission of
infection e.g., Hep A
 Periodic fluctuations;
1.Seasonal –measles (early spring)
2.cyclic-in pre-vaccinated era (peak 2-3 year)
 Long-term or secular trends; diabetes,
CVD
B. Place Distribution
 International variations:
Cancer of stomach very common in Japan
less common in US.
oral cancer- India
Breast cancer- Low-japan, high-western
 National variations, e.g. Distribution of fluorosis,
 Rural-urban differences, e.g.
CVD, Mental illness more common in urban areas.
Skin diseases, worm infestations more common in
rural areas.
 Local distributions, e.g. Spot maps- John Snow in
London to incriminate water supply as cause of
cholera transmission in London.
cholera cases in proximity to water
pump, 1854
 C. Person Distribution
Age: e.g.
Measles is common in children,
Cancer in middle age
Degenerative diseases in old age.
Sex:
Women- Lung cancer-less
Hyperthyroidism- more
c. Social class- Diabetes, Hypertenson– upper class
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 studies
 Cross-sectional study is an observational
study also called as prevalence study.
 It is based on single examination of
cross-section of population at one point
of time.
 If the sampling methodology is accurate,
results can be projected to the entire
population.
 They are more useful for chronic
illnesses, e.g. hypertension.
 Cross-sectional studies saves time and
resources but provide very little
information about natural history of
disease and incidence of illness.
 Case- control studies

 Itstart 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
 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 look 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 exposur
3. Selection of comparison groups
4. Follow-up
5. Analysis.
 CHD Develop CHD does total
not develop
Smoker 84 (a) 2916 (b) 3000 (a+b)

Nno-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.
Differences between case-control
and cohort studies

Case control Cohort study

Proceeds from effect to Cause to effect
cause Startswith the people
Starts with the disease. exposed to risk factor
Tests whether the Tests whether disease
suspected cause occur more occur more frequently in
frequently in those with exposed than in those not
disease than those without exposed
disease Reserved for testing of
1stapproach in testing precisely formulated
hypothesis hypothesis
 Case control  Cohort study
 Involves fewer study  Involves large number of
subjects subjects
 Yield results relatively  Long follow up, delayed
quicker result
 Suitable for study of  Not appropriate for rare
rare diseases. disease
 Generally, yields only  Yields incidence frates ,
relative risk (ODDS ratio) relative risk,
attributable risk
 Perspective
 Retrospective
 Can study more than one
 Can study only one
disease
disease
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.
Cessationexperiments, 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.
 Indouble 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
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