Principles of Epidemiology

Dona Schneider, PhD, MPH, FACE

Epidemiology Defined

Epi + demos + logos = that which befalls man The study of the distribution and determinants of disease frequency in human populations (MacMahon and Pugh, 1970)

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Epidemiology Defined

The study of the distribution and determinants of health-related states or events in specified populations and the application of this study to the control of health problems (John Last, 1988)

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Uses of Epidemiology

Identifying the causes of disease

Legionnaires disease

Completing the clinical picture of disease

Tuskegee experiment

Determining effectiveness of therapeutic and preventive measures

Mammograms, clinical trials

Identifying new syndromes

Varieties of hepatitis

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Uses of Epidemiology

Monitoring the health of a community, region, or nation

Surveillance, accident reports

Identifying risks in terms of probability statements

DES daughters

Studying trends over time to make predictions for the future

Smoking and lung cancer Estimating health services needs

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Life Table of Deaths in London

Age 0 6 16 26 36 46 56 66 76 80 Deaths -36 24 15 9 6 4 3 2 1 Survivors 100 64 40 25 16 10 6 3 1 0

Source: Graunts Observations 1662

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Graunts Observations

Excess of male births High infant mortality Seasonal variation in mortality

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Yearly Mortality Bill for 1632: Top 10 Causes of Death

Chrisomes & Infants Consumption Fever Collick, Stone, Strangury Flox & Small Pox
Bloody Flux, Scowring & Flux

Dropsie & Swelling Convulsion Childbed Liver Grown 0 500 1000 1500 2000 2500

Number of deaths
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Leading Causes of Death in US: 1900

Pneumonia Tuberculosis Diarrhea and enteritis Heart disease Chronic nephritis Unintentional injury Stroke Diseases of early infancy Cancer Diptheria 0 0 0 00 0 00 0 00 0 00 0 00 0

Death rate per 000 , 000

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Leading Causes of Death in US: 1990

Heart disease Cancer Stroke Unintentional injury Lung diseases Pneumonia and influenza Diabetes Suicide Liver disease HIV/AIDS

0
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50

100

150

200

250

300

Death Rates per 100,000

Endemic Vs. Epidemic

No. of Cases of a Disease

Endemic Time
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Epidemic

Population Pyramid

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1900

1940

1960

1980

2000

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Statistics

Statistics: A branch of applied mathematics which utilizes procedures for condensing, describing, analyzing and interpreting sets of information

Biostatistics: A subset of statistics used to handle health-relevant information

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Statistics (cont.)

Descriptive statistics: Methods of producing quantitative summaries of information

Measures of central tendency Measures of dispersion

Inferential statistics: Methods of making generalizations about a larger group based on information about a subset (sample) of that group

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Populations and Samples

Before we can determine what statistical test to use, we need to know if our information represents a population or a sample A sample is a subset which should be representative of a population

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Samples

A sample should be representative if selected randomly (i.e., each data point should have the same chance for selection as every other point) In some cases, the sample may be stratified but then randomized within the strata

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Example
We want a sample that will reflect a populations gender and age:
1. 2. 3.

Stratify the data by gender Within each strata, further stratify by age Select randomly within each gender/age strata so that the number selected will be proportional to that of the population

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Populations and Samples

You can tell if you are looking at statistics on a population or a sample

Greek letters stand for population parameters (unknown but fixed) Arabic letters stand for statistics (known but random)

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Classification of Data
Qualitative or Quantitative

Qualitative: non-numeric or categorical

Examples: gender, race/ethnicity

Quantitative: numeric

Examples: age, temperature, blood pressure

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Classification of Data
Discrete or Continuous

Discrete: having a fixed number of values

Examples: marital status, blood type, number of children

Continuous: having an infinite number of values

Examples: height, weight, temperature

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Hint

Qualitative (categorical) data are discrete Quantitative (numerical) data may be

discrete continuous

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Qualitative Data: Nominal

Data which fall into mutually exclusive categories (discrete) for which there is no natural order Examples:

Race/ethnicity Gender Marital status ICD-10 codes Dichotomous data such as HIV+ or HIV-; yes or no

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Qualitative Data: Ordinal

Data which fall into mutually exclusive categories (discrete data) which have a rank or graded order Examples:

Grades Socioeconomic status Stage of disease Low, medium, high

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Quantitative Data: Interval

Data which are measured by standard units The scale measures not only that one data point is different than another, but by how much Examples

Number of days since onset of illness (discrete) Temperature in Fahrenheit or Celsius (continuous)

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Quantitative Data: Ratio

Data which are measured in standard units where a true zero represents total absence of that unit Examples

Number of children (discrete) Temperature in Kelvin (continuous)

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Review of Descriptive Biostatistics

Mean Median Mode and range Variance and standard deviation Frequency distributions Histograms

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Mean

Most commonly used measure of central tendency Arithmetic average

Formula: x = x / n

Sensitive to outliers

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Example: Number of accidents per week 8, 5, 3, 2, 7, 1, 2, 4, 6, 2 x = (8+5+3+2+7+1+2+4+6+2) / 10 = 40 / 10 = 4

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Median

The value which divides a ranked set into two equal parts Order the data

If n is even, take the mean of the two middle observations If n is odd, the median is the middle observation

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Given an even number of observations (n=10): Example: 1, 2, 2, 2, 3, 4, 5, 6, 7, 8 Median = (3+4) / 2 = 3.5 Given an odd number of observations (n=11): Example: 1, 2, 2, 2, 3, 4, 5, 6, 7, 8, 10 Median = 4 (n+1)/2 = (11+1)/2 = 6th observation
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Mode

The number which occurs the most frequently in a set Example: 1, 2, 2, 2, 3, 4, 5, 6, 7, 8

Mode = 2

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Range

The difference between the largest and smallest values in a distribution Example: 1, 2, 2, 2, 3, 4, 5, 6, 7, 8

Range = 8-1 = 7

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Variance and Standard Deviation

Measures of dispersion (or scatter) of the values about the mean

If the numbers are near the mean, variance is small If numbers are far from the mean, the variance is large

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Variance
V = [(x-x)2] / (n-1) V = [(8-4) 2 +(5-4) 2 +(3-4) 2 +(2-4) 2 +(7-4) 2 +(1-4) 2 +
(2-4) 2 +(4-4) 2 +(6-4) 2 +(2-4) 2] / (10-1) =

V = 5.7777
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Standard Deviation

SD = V SD = 5.777 = 2.404

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Symmetric and Skewed Distributions

Symmetrical Skewed

Mean Median Mode

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Mean Median Mode

Frequency Diagrams of Symmetric and Skewed Distributions

Symmetric
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Skewed

12 Patients 5-point Anxiety Scale Scores

Patient Anxiety score
1 4 2 3 3 5 4 1 5 4 6 4 7 2 8 5 9 4 10 3 11 4 12 5

Score
1 2 3 4 5 Total
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Frequency
1 1 2 5 3 12

Frequency Diagram for 12 Psychiatric Patients

0 0

Frequency

0 0 0 0

Score
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Accidents at a summer camp requiring ER treatment

Week 1 2 3 4 5 6 7 8
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Frequency 1 3 1 1 1 1 1 1

Percent 10 30 10 10 10 10 10 10

Histogram
0 0

Frequency

0 0 0 0 0 0 0 0 0 0 0 0 0

Number of accidents per week

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Frequency Polygon
0 0

Frequency

0 0 0 0 0 0 0 0 0 0 0 0 0

Number of accidents per week

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Frequency Polygon and Histogram

Note: area A = A; B = B; C = C; D = D; area under histogram = to area under polygon
0 0 0 0 0 0
A B A C D D

Frequency

Number of accidents per week

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Descriptive Statistics

Used as a first step to look at health-related outcomes Examine numbers of cases to identify an increase (epidemic) Examine patterns of cases to see who gets sick (demographic variables) and where and when they get sick (space/time variables)

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