UNIVERSITY OF GONDAR

COLLEGE OF COMPUTATIONAL AND NATURAL SCIENCE

DEPARTMENT OF BIOSTATISTICS

EPIDEMIOLOGY GROUP ASSIGNMENT

Group members:

1 NEGASH NIGUS
2 ABDULMENAN MOHAMMED
3 BEZANESH MELESE

Submitted to: Mr.Kidanemariam Alem (MSc in biostatistics)

Date 03/04/2011 E.C
PART I:

A 12-year old boy presented with difficulty in breathing, cough and hemoptysis
of 10 days duration. The problem started suddenly while he was bathing in small river
at Muger (110 kms.Northwest of Addis Ababa). He was seen in a nearby clinic and
was referred to Tikur Anbessa Hospital when his condition worsened. Examination
on arrival revealed a restless boy with a respiratory rate of 60/min, pulse rate of
130/min, but no fever. He had audible inspiratory stridor with intercostal and sub-
costal retractions and air entry was markedly diminished over both lung fields. There
was non-clotting trickle of blood in the mouth. The boy was immediately taken to the
operation theatre and was given 100% oxygen by mask. Direct laryngoscopy was
performed under general anesthesia using ketamine, atropine and succinic choline
after oxygenation. A leech was seen about 0.5 cm distal to the vocal cords and was
extracted using biopsy forceps; it was alive and measured 5 cm in length. The child

1
improved markedly after the procedure and was discharged symptom free the next
day. What study design was used in this report? Why?
Answer: the study is a descriptive case report study design.

Because the report is telling us the experience and the health profile of a single patient
including the definition of the disease, when the disease is occurred, where the person
live(the patient) and personal characteristics of the patient, so the design used is a
case report study design.

In a hospital there were about 120 patients having diseases in the same degree.
These patients were divided into three groups and three different drugs were given
for each group to test the effectiveness of the drugs. The assignment of patients to
each treatment arm was random. The outcome variable is global assessment of
function (GAF). High score means better functioning and the observations vary from
0 to 100. What type of study design was used? Why?

Answer: Randomized clinical trial:

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Because the intervention taken was treatment based on drugs and the treatments are
used as an exposure and better functioning is the outcome of interest, also the study
participants were persons with disease.

 Performed in clinical setting and the subjects are patients.

 The assignment of patients to each treatment was randomly assigned

 Used to test the effectiveness of the drugs, so by all of this things the study is a
randomized clinical trial.

What is the difference between statistical significance and clinical significance?

Answer:
Statistical significance has to do with the likelihood that a research result is true (i.e.,
a real effect of the intervention) and not merely a matter of chance and also tells
us how likely a research result is a chance finding based on the researcher’s
predetermined significance level. Statistical significance is a function of sample

3
size. If you have a large enough sample size, almost anything can be found to be
statistically significant.
Clinical significance: the practical importance of the treatment effect whether it has
a real, noticeable effect on daily life. If the treatment makes a positive and noticeable
improvement on a patient it is clinically significant or important.
It is sometimes called clinical importance or practical importance. There is no an
“official” or gold standard definition of clinical significance because the criteria will
change depending on the disease, condition, or patient population.
It is a subjective interpretation of a research result as practical or meaningful for the
patient and thus likely to affect provider behavior, this term is generally accepted as
the practical significance of the research or how meaningful the results would be to
the patient? For example, will you change your prescribing behavior or treatment of
certain patient populations as a result of the research findings?
Suppose a new test named “Test X" is developed for screening of cervical
cancer. This new test was applied on 500 known early cases of cervical cancer and

4
550 women without cervical cancer. The test was positive for 450 women with
cervical cancer and 30 women without cervical cancer.
A. Show the results by 2X2 table
B. How do you determine the validity of Test X? Calculate and interpret the measures
of validity.
C How do you determine the predictive value of Test X? Calculate and interpret the
predictive value of Test X.

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Answer: for A,
Test Results Disease status

Cases Controls Total

Positive 450 (a) 30 (b) 480 (a+b)

Negative 50 (c) 520 (d) 570 (c+d)

Total 500 (a+c) 550 (b+d) 1050 (a+b+c+d)

Answer for B,
Validity is the extent to which data collected actually reflect the truth. The concepts
of sensitivity (ability to detect true positive) and specificity (ability to detect true
negatives) can be used to characterize the validity of a measure ("measurement
validity").
The measures of validity are:

6
Sensitivity: the proportion of people with a disease who have a positive test for the
disease.
Sensitivity = a/(a+c) =400/(450+50)=0.9=90%
Interpretation: 90% of the women with cervical cancer correctly identified as
diseased (test positive).
But, 10% of women who had cervical cancer classified as free diseased (false
negative)
Specificity: is the proportion of people without the disease who have a negative test
Specificity= d/(b+d)=520/(30+520)=0.95=95%
Interpretation: 95% women without cervical cancer (disease) identified
Correctly (true negative).
But, 5% women who did not have cervical cancer classified (false positive).
Answer for C,

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  Predictive value is the ability of a test to predict the presence or absence of
disease from test results. And Predictive value of a test is determined by
Sensitivity, Specificity and the Prevalence of the disease.

Positive predictive value: is the probability of the presence of the disease in a person
with a positive test result.
𝑎 450
(+PV = = =0.94=94%
𝑎+𝑏 450+30

Interpretation: 94% of the women with positive test result really have the disease.

Negative predictive value: is the probability of not having the disease when the test
result is negative.
𝑑 520
(-PV = = =0.91=91%
𝑐+𝑑 50+520

Interpretation: 91% of the women with negative test result really have no cervical
cancer

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 Cohort study was conduct to identify the risk of death among patients with
heart attack who are smoker and nonsmoker. The result of the study was given by
table below.
Heart attack Smoker Quit Total
patients

Death 27 14 41

Survival 48 67 115

Total 75 81 156

A. Calculate OR/RR.

The appropriate measure of association to identify the risk of disease among

patients is relative risk. So,

RR=Incidence among exposed/Incidence among non-exposed

RR= a/ (a+b)/c/(c+d)=27/ (27+14)/48/(48+67)=27/41*115/48=1.57

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B. Interpret the result of OR/ RR.

Interpretation: patients who smoked had 1.57 times higher risk of death with heart
attack when compared to non-smokers.

C. Construct 95%CI for OR/ RR. The 95% confidence interval for log (RR)

a/(a+b)= 27/(27+14)=0.66, RR=1.57, the estimated( RR) is Ln(RR) =Log(1.57)

=0.195

c/(c+d)= 48/(48+67)=0.42

The estimated standard error for log (RR) =√b/an1+d/cn2)=

√14/27*41+67/48*115) =0.158

Then, The 95% confidence interval is log(RR)+_1.96(0.158)=(0.195-

0.31,0.195+0.31)

=(-0.115,0.505)

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Thus, a 95% confidence interval for the true RR is obtained by exponentiation the
interval for log (RR):

(𝑒 −0.115 , 𝑒 0.505 )= (0.89, 1.65) interval contain 1, therefore it is not

significant.

There were 6000 deaths (1200 leukemia, 1750 stroke, 250 pneumonia, 250
Hodgkin’s disease, and 2500 acute myocardial infarction) in Cook County, which had
a population of 2.5 million in 1991.
A. Compute the cause specific death rare for acute myocardial infraction
Cause specific death rate (CSDR) =
number of death due to acute myocardial infection 2500
*10^n= *100,000=100 acute myocardial
total population of period 2500000

infraction per 100,000 population.

Therefore, 100 people died due to acute myocardial infraction per 100,000
population.

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B. Compute the proportionate mortality rate for leukemia
death due to leukemia
Proportionate mortality rate= *100
death from all cases

1200
= *100=20%
6000

So, the proportionate mortality rate causes by leukemia is 20% out of 6000 number
deaths.

Suppose you are interested to study whether consumption of high amount of

salt causes hypertension. How do you conduct ecological study to assess this
association? Explain using Examples.

An ecological study Uses data from entire population to compare disease frequencies
between different groups during the same period of time, or in the same population
at different points in time.

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A large number of epidemiologic, evolutionary, and clinical studies have confirmed
that salt intake is an important factor in elevating the blood pressure in human.

Let us consider two different group of populations with high and low salt intake:

To determine the association between the salt intake and hypertension we can
perform the following measures for both populations of interest in the same time and
have to follow ecological investigation through steps.

Measures:

For both populations determine the urinary excretion of sodium

(UVNa) and the level of the mean of both systolic BP and diastolic
BP.

Based on the results of each population determine the level of the

mean of both systolic BP and diastolic BP in comparison of the high

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and low amount of the urinary excretion of sodium in which high
level of the mean of both systolic BP and diastolic BP implies the
higher hypertension.

Finally we can make a comparison between the two populations of

interest.
We can follow some steps to assess this associations:

Step 1: Define the problem and setting Objectives

Define the difference between individual and group characteristics

 Define the source population for the study

 Describe sources of information for ecological studies

For example, let us define source of population as the two study groups coming from
the same source population. This would allow us to compare incidence of

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hypertension in the two groups. Imagine Population A (those who use high amount
of salt) and population B (those who do not use high amount of salt)

Step 2: Formulate hypothesis the ecological study relates group (or aggregate)
characteristics to rates in each group.

 the appropriate hypothesis to assess this association is population who consume

high amount of salt has higher incidence rate of hypertension than population
who do not consume high amount of salt

Step 3: Study Design

 We use ecological study design, because we need data at the population level
rather than the individual level.

Step 4: Data Collection With our hypothesis and source population defined, we now
need to determine where we will get the necessary data. Ecological studies involve
comparison and analysis of variables at the population level.

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  We will need to know the number of new cases of hypertension as well as their
addresses.
 Additionally, we need to know the population size of these areas and the amount
of salt used during a given time period

Step 5: Data Analysis

 Calculate incidence rates (The correlation coefficient denoted by ‗r‘ is the

descriptive measures of association in ecological studies and it quantifies the
extent to which there is a linear relationship between exposure and disease that
is whether for every unit of change in level of exposure, the disease frequency
increases or decreases proportionately. Correlation coefficient varies ranging
from positive one to negative one) and interpret the results.
 Plot incidence rate against exposure in order to show the correlation between
incidence rates of hypertension vs high consumption of salt and less amount of
salt consumption based on their daily consumption of salt.

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Step 6: Drawing conclusion using the ecological study design, we can only draw
conclusions concerning the groups or populations under analysis. We cannot draw
conclusions about the individual members of the population because we do not have
exposure and outcome data on each member.

Example
A study in Yi (an ethnic minority living in southwestern china) farmers who lived in
a remote mountainous environment and consumed a sodium-poor a BP rose very little
with increasing age (0.13 and 0.23mmHg/year for systolic and diastolic respectively).
In contrast a Yi migrants and Han people who lived in urban areas consumed a
sodium-rich diet and experienced a much greater in BP with progressive aging (0.33
and 0.33mmHg/year for systolic and diastolic respectively).

Another study in Kenya showed that a migrants who had higher mean urinary sodium
compared to the non-migrants had higher systolic BP. BP rose after a few months
(6.9/6.2mmHg systolic and diastolic), whereas it did not increase in non-migrant.
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 PART II: Say True/False With Specific Reasons

Answer: false

Justification: cross-sectional study Examines relationship between exposure and

outcome and it is a health outcome prevalence in a defined population at a single
point in time (point prevalence) or over a period of time (period prevalence).

A cross sectional study with internal comparison can be used to estimate

prevalence and identify risk factors.

Answer: false
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Justification: The prevalence can be calculated in cross-sectional studies as a measure
of frequency. The prevalence describes how frequently a specific disease or a specific
risk factor occurs in a population at a defined point in time. Involve comparisons of
the incidence of disease or infection in risk-factor in the study population.

Answer: True

Justification: Epidemiologic design in which the two comparison groups are defined
according to their exposure status to a suspected risk factor of a disease is cohort.
Subjects are defined according to their exposure levels and followed over time for
outcome occurrence

A case-control study design is preferred to evaluate effectiveness of public

health interventions with ethical concerns.

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Answer: false

Justification: A case-control study design Examines multiple exposures in relation to

an outcome, used to evaluating the association of a disease to exposure, but
experimental study preferable to assess the efficacy of drugs, treatments,
interventions. So, this is the aim of experimental study.

An incidence case-control study for a rare disease is less time consuming than
a prospective cohort study for a common disease.

Answer: True

Justification:

 Optimal for the evaluation of RARE diseases

 Quick and inexpensive

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Answer: false

Justification: Follow up is the major challenge in cohort studies, as well as the major
cost in terms of time. Unless complete or nearly complete information could be
obtained the results might be un-interpretable. If the loss to follow-up is not
comparable between the two exposed groups, this will also be a source for bias.
Therefore, Minimizing loss to follow up is the best way to eliminate bias.

Answer: True

Justification: Qualitative Research is primarily subjective in approach as it seeks to

understand human behavior and reasons that govern such behavior. “It forces the
interviewed person to think about motivations and reasons for a certain behavior

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Answer: False

Justification: It is always prospective It has essentially the same design as prospective

cohort study with one very key difference, exposure status of the study population is
deliberately changed by the investigator to observe how this alters the incidence of
disease or other features of the natural history

Answer: True

Justification: Interventional studies are often prospective and are specifically tailored
to evaluate direct impacts of treatment or preventive measures on disease and
prospectively to assess the effectiveness of the intervention.

Answer: True

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Justification: blind data collectors regarding exposure or health outcome status and
develop well standardized data collection protocols can help to minimize information
bias

Answer: false

Justification: large sample improve data analysis, reducing random error in the way
information is obtained and recorded, less sampling process error, not related in
reducing information bias.

Answer: false

Justification: the primary objective in epidemiology is to judge whether an

association between exposure and disease is, in fact, causal, but scientific proof of a
cause effect relationship is often difficult to obtain, since experimental studies are

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often neither feasible nor ethical. So, one must assess the validity of individual studies
and examine the totality of evidence from all available studies and make a judgment
about the likelihood of a cause effect relationship.

Answer: True

Justification: Train interviewers to obtain data in a standardized manner and

technicians well, perform pilot studies to identify problems with questionnaires and
measuring instruments are important in reducing information bias.

Answer: False

Justification: Selection bias can be reduced by paying attention to the following: The
study population should be clearly identified, the choice of the right comparison/

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reference group, select participants through randomization, so that they have an equal
chance of receiving the intervention.

Answer: True

Justification: The large size of many populations can provide less reliable information
than a carefully obtained sample and sampling bias on the other hand may be
minimized by the wise choice of a sampling procedure.

Answer: True

Justification: Sensitivity: The number of positive test results for the presence of an
outcome (a) divided by the total presence of an outcome (a+c) Sensitivity = a / (a+c)

Epidemiologists have found that accidents can be avoided and are predictable.

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Answer: True

Justification: Epidemiology is the study frequency, distribution and determinants of

diseases and other health related states or events such as injuries, accident and
disability in specified populations. Refers to an accident as a sequence, chain of
events, or series of interactions between the person and environment or agent,
including the measurable or recognizable consequences.

An epidemic is a disease occurring over a wide geographic area and affecting

a high proportion of the population.

Answer: False

Justification: Pandemic refers to an epidemic that has spread over several countries
or continents, usually affecting a large number of people, but an epidemic is the rapid
spread of infectious disease to a large number of people in a given population within
a short period of time.

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 An endemic is an occurrence of disease clearly in excess of normal expectancy.

Answer: False

Justification: Epidemic refers to an increase, often sudden, in the number of cases of

a disease above what is normally expected in that population in that area.

In measuring the reliability of a measurement, an intra-examiner or intra-

reliability is consistency of findings by one examiner with those previously recorded
by the same examiner. Answer: True

Justification: Inter-examiner reliability refers to the consistency of the readings of the

same subjects between the two examiners, while intra-examiner reliability refers to
the consistency of the readings of the same subject by the same examiner

. Oral epidemiology is the study of disease and health in populations.

Answer: True

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Justification: Oral epidemiology can be defined as the study of distribution and
determinants of oral health related states or events in specified population.

. Morbidity is the rate of disease or proportion of diseased persons in a

geographic area. Answer: True

Justification: It is one measure of disease occurrence and health related events in a

geographic area(i.e. prevalence and incidence)

. Mortality is the proportion of people who live from a disease to the population
of a geographic area for a period of time.

Answer: False

Justification: Mortality is the proportion of people who died from a disease to the
population of a geographic area for a period of time

A count is a percentage method to measure oral disease.

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Answer: False

Justification: In oral epidemiology, there are a number of crucial terms that will help
dentists to understand how oral disease data is measured and presented. These include
Index: This is a standard method of rating a disease in which there is a graduated,
numerical scale with values corresponding to specific criteria

Morbidity is also known as the death rate in a population.

Answer: False

Justification: Morbidity is not death rate, but it is the rate of disease or proportion of
diseased persons in a geographic area

. Environmental epidemiology is the study of disease and the conditions linked

to indoor factors.

Answer: False

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Justification: Environmental epidemiology studies external factors that affect the
incidence, prevalence, and geographic range of health conditions. Environmental
epidemiology seeks to understand how physical, chemical, biologic, as well as, social
and economic factors affect human health.

. A study was made of a clinician's ability to diagnose streptococcal throat

infections in 149 patients coming to the emergency department in a certain hospital.
The doctor's clinical impressions were compared to results of throat cultures or group
A streptococcus. 37 patients had positive throat cultures and 27 of these were
diagnosed by doctor as having strep throat. 112 patients had negative cultures, and
the doctors diagnosed 35 of these as having strep throat. The specificity of the doctors'
clinical judgment was

A. 27/37 B. 77/112 D. 10/87 C. 27/62 E. 104/149

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 Answer: B

Justification: Specificity is the proportion of people without the disease who have a
negative test (d/ b+d ).

Test result DISEASE STATUS

Disease present Disease absent Total

Positive 27(a) 35(b) 62 (a+b)

Negative 10(c) 77(d) 87 (c+d)

Total 37 (a+c) 112(b+d) 149 (a+b+c+d)

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 .A longitudinal or prospective study is also referred to as a(n)

A. ecological study

B. cross sectional study

C. cohort study

D. observational study

Answer: C

Justification: longitudinal/prospective study is also known as cohort study. Cohort

studies are observational studies in which the starting point is the selection of a study
population, or cohort. Information is obtained to determine which members of this
cohort are exposed to the factor of interest. The entire population is then followed up
over time and the incidence of the disease in the exposed individuals is compared
with the incidence in those not exposed.

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 . Cedar Rivers is a community of 100,000 persons in central Iowa. During the
year of the floods (2008 there were 1,000 deaths from all causes. A study of all cases
of tuberculosis found the number of deaths at 300 (200 males and 100 females).
During 2007, there were only 60 deaths from tuberculosis, 50 of them males. The
crude mortality rate for Cedar Rivers in 2008 was

A. 300 per 100,000

B. 60 per 1,000

C. 10 per 1,000

D. 100 per 11000

Answer: C

Justification: The crude mortality rate it the death rate that is calculated using all
deaths as the numerator and the total population as the denominator. Therefore Crude
mortality rate = total deaths/total population = 1000 100000 *100 = 10 per 1,000

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A. Native B. Epidemiology C. People D. All

Answer: C

Justification: The word Epidemiology comes from the Greek words epi, meaning on
or upon, demos, meaning people, and logos, meaning the study of.

A. are used very commonly in environmental epidemiologic research. An example

may be possible health effects of exposure to electromagnetic fields.

B. Allowance of the direct observation of risk. The exposure factor is well defined
and can study exposures that are uncommon in the population. The temporal
relationship between factor and outcome is known.

C. the units of analysis are groups. This can be referred to as an Ecological

Comparison Study.
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Answer: A

Justification: Epidemiologic research methods in which the two study groups are
selected on their disease status. The design is capable of evaluating the association of
a disease to exposure, optimal for the evaluation of RARE diseases, can examine
multiple etiologic factors for a single disease.

A. It is the best because if the sensitivity test correctly identifies all potential cases as
either negative or positive.

B. A clinical trial refers to a research activity that involves the administration of a

test regimen to humans to evaluate its efficacy and safety.

C. This is the association between two variables, the exposure and the outcome, and
are measured at the group level.

Answer: C

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Justification: ecologic correlation uses data from entire population to compare
disease frequencies - between different groups during the same period of time, or in
the same population at different points in time.Does not provide individual data,
rather presents average exposure level in the community.

A. the measurement of exposure may be inaccurate. Representativeness of cases and

controls may be unknown and may provide indirect estimates of risk. The temporal
relationship between exposure factor and outcome cannot always be determined.

B. This is beneficial because an association can be found between exposure rates and
disease rates during the same time period.

C. The predictive value is the proportion of people screened positive by a test and
actually have the disease, this is the + value.

Answer: B

36
Justification: ecologic study is used to assess an association that can be found
between exposure rates and disease rates at group level rather than individual.

A. is designed to test preventive measures

B. evaluates new treatment methods

C. involves the administration of a test regimen to humans to evaluate its efficacy

and safety. Answer: B

Justification: concerned with the treatment of disease and action of remedial agents.
The sample should be sick individual to evaluate new treatment methods.

A. When sensitivity tests correctly identify all potential cases as either negative or
positive

37
B. Describes when a definitive diagnosis that has been determined by biopsy, surgery,
autopsy or other method and has been accepted as the standard.

C. Where the investigator manipulates the study factor but does not assign individual
subjects randomly to the exposed and non-exposed groups

Answer: C

Justification: When investigator assigned exposure based on non-random

mechanisms but the investigator control factor under the study.

A. This is the generalizing of the study to the population

B. Was the conclusion true? It is the extent to which you can believe your results

C. It is the third variable that relates to the exposure and the outcome

Answer: A

38
Justification: It concerns generalizability, or inferences to populations beyond the
study's restricted interest. External validity is threatened, for example, when the
investigator attempts to apply the findings of the study to a population which is not
comparable to the population in which the research was completed.

A. Person to Animal

B. Person to Person

C. Object to Person

Answer: B

Justification: Indirect Transmission- an agent is carried from reservoir to a

susceptible host by suspended air particles or by animate (vector-mosquitoes, fleas,
ticks...) or inanimate (vehicle-food, water, biologic products, fomites) ,But person to

39
person transfer of the agent from a reservoir to a susceptible host by direct contact or
droplet spread .

A acquired immunity from previous exposure to an agent before a vaccine or natural

infection

B. Resistance of the entire community because of the people immunity within the
community

C. Immunity gained from a person to person transaction

Answer: C

Justification: A short-term immunity resulting from the introduction of antibodies

from another person or animal. It has lesser role in the control of communicable
diseases than active immunization: Example; Transfer of maternal antibodies to the
fetus through the placenta

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A. Experimental

B. Observational cohort

C. Observational case-control

D. Observational cross-sectional

E. Not an analytical or epidemiologic study

I ____D______ Representative sample of residents were telephoned and asked how

much they exercise each week and whether they currently have (have ever been
diagnosed with) heart disease.

Answer: D

Justification: Cross sectional study investigate disease and risk factor (exposure)
patterns in a representative sample of a population in a narrowly defined time period.

41
It can be useful to identify associations, generate and test hypothesis and, by repeating
at different time periods, measure change and hence evaluate interventions.

II. ____B______ Occurrence of cancer was identified between April 1991 and July
2002 for 50,000 troops who served in the first Gulf War (ended April 1991) and
50,000 troops who served elsewhere during the same period.

Answer: B

Justification: Participants classified according to exposure status and followed up

over time to ascertain outcome

III. ____C______ Persons diagnosed with new-onset Lyme disease were asked how
often they walk through woods, use insect repellant, wear short sleeves and pants,
etc. Twice as many patients without Lyme disease from the same physician’s practice
were asked the same questions, and the responses in the two groups were compare

Answer: C

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Justification: An “observational” design comparing exposures in disease cases vs
healthy controls from the same population, Subjects are selected with respect to
presence or absence of disease or outcome of interest, and then inquiries are made
about past exposure to the factor(s) of interest. Can examine multiple etiologic factors
for a single disease

IV. ____A______ Subjects were children enrolled in a health maintenance

organization. At 2 months, each child was randomly given one of two types of a new
vaccine against rotavirus infection. Parents were called by a nurse two weeks later
and asked whether the children had experienced any of a list of side-effects.

Answer: A

Justification:

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 n of many treatments or procedure

1. Strength of the Association - The stronger the association, the more likely that it is
causal.

2. Consistency of the Relationship - The same association should be demonstrable in

studies with different methods, conducted by different investigators, and in different
populations.

3. Specificity of the Association - The association is more likely causal if a single

exposure is linked to a single disease.

4. Temporal Relationship - The exposure to the factor must precede the onset of the
disease.

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5. Dose-response Relationship - The risk of disease often increases with increasing
exposure to a causal agent.

Q 90, why do we study Epidemiology?

Epidemiology is the study of the distribution and determinants of health-related

states or events in human populations and the application of this study to the control
of health problems. The core of epidemiology is the use of quantitative methods to
study disease and risk factors in human populations.

Its principles and methods are used to: describe the health of populations; detect
causes of health problems, quantify the association between ill health and
determinants, test treatments and public health interventions; and monitor changes in
states of health over time.

The main roles of epidemiology:

Community health assessment and priority setting

45
To set policy and plan programs, public health officials must assess the health of the
population or community they serve and determine whether health services are
available, accessible, effective, and efficient. To do this, they need to find answers
for many questions such as:

What are the actual and potential health problems in the community?

Where are they?

Who is at risk?

Which problems are declining over time?

Which ones are increasing or have the potential to increase?

How do these patterns relate to the level and distribution of services available?

The methods of descriptive and analytic epidemiology provide ways to answer these
and other related questions.

46
Epidemiology uses community diagnosis as approach to identify community health
need. Community diagnosis is a process of identification and detailed description of
the most important health problems (what is the interest of the community? what they
need to be solved for them?) of a given community.

In order to prioritize these community health problems the following criteria should
be considered

The first criterion is magnitude of the problem.

The second criterion is severity of the health problem.

The third criterion is feasibility.

The fourth criterion is community concern.

The fifth criterion is government concern.

47
Finally, add up all the scores given for every criterion for specific disease or health
problem and prioritize according to rank. The disease or health problem with the
highest scores will be given priority in that community.

Identification for cause of disease:

Many of the known causes of diseases are identified using epidemiologic methods.

Basic tool for investigation of outbreak:

Outbreaks caused by new diseases or existing diseases can be investigated using

epidemiological methods.

o In most cases, epidemiology is able to identify the causes of the outbreaks

E. g. John Snow’s investigation of the cholera outbreak

Evaluation of health interventions and programs:

o Epidemiological studies of the efficacy and effectiveness of health

interventions provide information for identifying appropriate interventions this

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 means determining things such as the appropriate length of stay in hospital for
specific conditions, the value of treating high blood pressure, the efficiency of
sanitation measures to control diarrheal diseases will be evaluated for their
effectiveness and efficiency using epidemiological methods.

o Epidemiological principles and methods are also used in evaluating health

policies and programs

Improving diagnosis, prognosis and treatment:

Epidemiological research contributes to identification of appropriate tests and criteria

for diagnosis and screening tests. Epidemiological research can help to determine the
most effective treatment and the likely outcome of patients essential for planning
care.

o Improving diagnosis through acceptable accuracy

o Improving treatment through drug clinical trial

Understanding natural history of disease:

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When studying a disease outbreak, epidemiologists depend on clinical physicians and
laboratory scientists for the proper diagnosis of individual patients. However,
epidemiologists also contribute to physicians’ understanding of the clinical picture
and natural history of disease. Preventing disease and promoting health: Much of
epidemiologic research is devoted to a search for causes, factors that influence one‘s
risk of disease. This will directly or indirectly helps the scientific community to
design different disease prevention mechanism. It is known that epidemiology can
never prove a causal relationship between an exposure and a disease. Nevertheless,
epidemiology often provides enough information to support effective action.

Screening programs:

The basic principles of epidemiology are applied in the planning and execution of
screening program.

o Screening is early detection of disease in apparently healthy individuals

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 o Screening and early treatment of diseases is one of the main strategies of disease
prevention program in public health practice

Preventing disease and promoting health

o Epidemiological studies contribute to the understanding of the causes, modes

of transmission, natural histories and control measures of diseases

o It is essential for developing appropriate health promotion strategies to prevent

disease

o Epidemiological studies can provide information on the effectiveness of health

promotion interventions

Diseases may occur in a community at different levels at a particular point in

time. Some diseases are usually present at a predictable level. This is called the

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expected level. But sometimes disease may occur in excess of what is expected level.
In epidemiology the concept epidemic and pandemic are used to describe the level of
the disease occurrence in the community.

It is a disease that occurs in a population at expectable level with predictable

regularity and a persistent level of low to moderate occurrence. Diseases having more
or less stable frequency. It may be hyper endemic, meso-endemic or hypo endemic.

Hyper endemic is an endemic disease that affects a high proportion of the population
at risk.

Meso endemic is an endemic disease that affects a moderate proportion of the

population at risk. Hypo endemic is an endemic disease that affects a small proportion
of the population at risk.

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If occurrence of a health-related event within an area or population that is clearly in
excess of the expected level for a given time period then the occurrence level is
Epidemic outbreak.

An epidemic involving several countries or continents affecting a large number

of people. The term epidemic may include any kind of disease or injury including
non-infectious diseases. There is no general rule about the number of cases
that must exist for a disease to be considered as an epidemic. If the number of
cases exceeds the expected level on the basis of past experience of the particular
population, then it is an epidemic occurrence. It is important to note that this level
varies for different diseases and different circumstances. A single case can be
considered as an epidemic if the disease is not expected to occur. For example: a
report of one case of small pox at the present time may be considered as an
epidemic.

Q 92, what were early conceptions of the cause of disease?

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Early Concepts of Disease

Many early conceptions of the cause of disease were rooted in superstitions and
religion. Many felt that disease was punishment from God (or Gods depending on
their faith) and would pray or try to make amends with the God(s) they angered to
cure themselves of disease

 Early explanations for the occurrence of disease focused on superstition, myths,

and religion. Primitive peoples believed in natural spirits that were sometimes
mischievous or vengeful.

 The shift from the hunter-gather mode of living to an agricultural model

provided a more secure supply of food and enabled expansion of the
population. However, domesticated animals provided not only food and labor;
they also carried diseases that could be transmitted to humans.

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  Physical environment: safe water and clean air, healthy workplaces, safe
houses, roads, access and use of services drinking and eating pattern of the
people

 Prevailing etiologic theory was "miasma“ (i.e .poisoning by foul emanations

from soil, air, and water

 Disease is caused by the odor of decaying organic material in the environment.

Hunter-Gatherers

Ten thousand years ago humans were hunter-gatherers. They had a short life span,
but not because of epidemics; their primary problem was just finding enough food to
eat. They lived and traveled in small groups and hunted and foraged for food. Their
mixed diet was probably fairly balanced and nutritionally complete.

Mythology, Superstition, and Religion

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Early explanations for the occurrence of disease focused on superstition, myths, and
religion. Primitive peoples believed in natural spirits that were sometimes
mischievous or vengeful

The Agricultural Revolution

The shift from the hunter-gather mode of living to an agricultural model provided a
more secure supply of food and enabled expansion of the population. However,
domesticated animals provided not only food and labor; they also carried diseases
that could be transmitted to humans. People also began to rely heavily on one or two
crops, so their diets were often lacking in protein, minerals, and vitamins. People
began living in larger groups and staying in the same place, so there was more
opportunity for transmission of diseases.

Garbage and waste accumulated, and rodents and insect vectors were attracted to
human settlements, providing sources of disease. The engraving below shows a
woman emptying her bedpan into the street of a medieval village.

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The Hippocratic Corpus

For many centuries explanations for disease were based not on science, but on
religion, superstition, and myth.

The Hippocratic Corpus was an early attempt to think about diseases, not as
punishment from the gods, but as an imbalance of man with the environment.
Although it was unsophisticated by today's standards, it was an important step
forward. By considering the possibility that disease was associated with
environmental factors or imbalances in diet or personal behaviors, the Corpus also
opened up the possibility of intervening to prevent disease or treat it.

Despite the contributions of the Corpus, medical and scientific progress in Europe
was arrested for several centuries. The population grew, and cities became densely
populated, but there was little attention to waste disposal and sanitation. These factors
set the stage for endemic disease and periodic epidemics.

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The Bubonic Plague (1347-1700s)

Bubonic plague is an acute infectious disease caused by the bacterium Yersinia pestis.

Starting in 1347, Europe experienced multiple waves of bubonic plague epidemics

that lasted until the late 1700s. It is believed that the bubonic plague originated in
Asia and traveled along trade routes into the Black Sea and then into the
Mediterranean Sea. From there, it swept through Sicily and Italy and then up through
France and the northern European countries all the way up into Scandinavia. There
were many subsequent waves of plague that swept through Europe until the late
1700s

Cause of the Plague and Strategies for Prevention

The cause of the plague was not known, but there were many theories. The most
popular explanation was that it was caused by "miasmas," invisible vapors that
emanated from swamps or cesspools and floated around in the air, where they could

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be inhaled. Others thought it was spread by person to person contact, or perhaps by
too much sun exposure, or by intentional poisoning.

The miasma theory was the most popular, however. One of the popes kept large fires
burning at both ends of the room he worked in order to counteract the miasmas. The
illustration on the left shows a "plague doctor," who is covered from head to toe,
including a hood, a mask, gloves, and a beak-like sack on his nose. The covering on
the nose contained aromatic herbs, which were believed to neutralize miasmas

Quarantine and Isolation

The use of quarantine as a public health measure dates back to the 14th century
when the Black Death ravaged Italy and the rest of Europe. Quarantine comes from
the Italian quarantena, meaning forty-day period. Travelers and merchandise that
had potentially been exposed to disease were isolated for a period of time to ensure
that they weren't infected.

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In the history of community health and public health nursing, there were many
milestones that to some levels were impeding the progress of ensuring community
health and public health nursing.

Milestones have been broadly divided into four stages:

 Era of sanitary statistics:

 Prevailing etiologic theory was "miasma" (i.e., poisoning by foul emanations
from soil, air, and water).
 Disease is caused by the odor of decaying organic material in the environment.
 Dated back to the Hippocratic idea that disease is related to climate/connection
between the atmosphere and disease.
 Focused on assessing the clustering of morbidity and mortality and on
preventive measures and dramatically reduced incidence of infectious diseases
 Era of infectious disease epidemiology
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The germ theory prevailed (1862–Luis Pasteur’s proof of the Germ Theory of
diseases (figured out how diseases are spread)

 Period of bacteriology”
 laboratory isolation and culture
 Preventive approach
 interrupt transmission of the infectious agent
 Era of chronic disease epidemiology
 Focus on risk factors at individual level Germ theory: infectious disease era.
 The "black box" approach
 Exposures are related to outcomes without understanding the intervening
factors or pathogenesis (SusserandSusser1996).
 Primary analytic methods
 Risk ratios to relate exposures to outcomes.
 Preventive measures

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 Number of epidemiologists grown rapidly along with epidemiology training
programs
 Many sub-specialties have been established
 Multi-level causality
 focus on risk factors as well as casual pathways at the societal level and with
pathogenesis at the molecular level
 Cascade of causation from risk factors to molecular causes of diseases.
 Elaborated on the host-agent-environment harmony where in each of these
factors affects the other

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Historical Evolution of Epidemiology

Although epidemiology as a discipline has blossomed since World War

II, epidemiologic thinking has been traced from Hippocrates through John
Graunt, William Farr, John Snow, and others. The contributions of some
of these early and more recent thinkers are described below.

Although epidemiological thinking has been traced to the time of

Hippocrates, the discipline did not flourish as an independent discipline
until the 20th century. Some key dates and contributions to the
development of epidemiologic thinking and methods include:

460 B.C– Hippocrates, the father of modern medicine. For the first time
in the fifth century B.C. he suggested that the development of human
disease might be related to the external as well as personal environmental
of an individual.

1662 - John Graunt published Natural and Political Observations on the

Bills of Mortality. He was the first to quantify patterns of birth, death and
disease occurrence, noting male-female disparities, high infant mortality,
urban-rural differences, and seasonal variations.

1747 - Lind used an "experimental" approach to prove the cause of scurvy

by showing it could be treated effectively with fresh fruit.

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1787-1872. Pierre Charles Alexandre Louis, sometimes called the “Father
of Epidemiology”, systematized the application of numerical thinking (“la
methode numerique”) and championed its cause. Using quantitative
reasoning, he demonstrated that bloodletting was not efficacious therapy,
and wrote books on tuberculosis and typhoid. NLouis' influence was
widespread, primarily through his students.

William Farr, William Guy, William Budd (all students of Louis) –

founded the Statistical Society of London.

1839 - William Farr took responsibility for medical statistics in the Office
of the Registrar General for England and Wales. He extended the
epidemiologic analysis of morbidity and mortality data, looking at effects
of marital status, occupation, and altitude.

1854 - John Snow demonstrated that the risk of mortality due to cholera
was related to the drinking water provided by a particular

supplier in London. He used a "natural experiment" to test his hypothesis.

In another study conducted by Snow in 1854, he linked

an epidemic of cholera to a specific pump, the "Broad Street Pump".

According to literatures, Snow removed the handle of that pump and
aborted the cholera epidemic.

1937 Austin Bradford Hill, mainly worked on the Principles of Medical

Statistics and suggested the criteria for establishing causation.

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1950's-1970's. Major epidemiology successes in the area of – fluoride,
tobacco, blood pressure and stroke, CHD risk factors, toxic shock
syndrome, Legionnaire's disease, Reye’s syndrome, endometrial cancer
and exogenous estrogens.

The scientific method is a series of steps followed by scientific

investigators to answer specific questions about the natural world.

IT is a rigorous, time tested process for determining the probable truth of

any cause-and-effect proposition. The proposition is known as a
hypothesis. The method of testing is experimentation. The process has six
steps. Step-

step 1. Define the specific problem.

Step-2. Collect information by making observations.

Step-3. Formulate a hypothesis that explains the phenomenon.

Step-4. Test the hypothesis by experimentation.

Step-5. Accept, reject, or modify the hypothesis

Step-6. Draw a conclusion and report the results of the experiment.

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 Fig 1 steps of the scientific method.

Step-1. Define the specific problem.

 There are various forms of this step. Sometimes you may want to
state an objective and a problem and then phrase it in the form of a
question. The reason it’s good to state a question is because it’s

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 easiest to design an experiment to answer a question. A question
helps you form a hypothesis, which focuses your study.

 It involves recognizing and stating a very specific question

Step-2. Collect information by making observations.

 -Gathering data on the problem, and involves making an

observation about something that interests us.

Step-3. Formulate a hypothesis that explains the phenomenon.

 - we must formulate a question about what we have observed and

our question concerns about what it is that you are trying to discover
in our experiment. This is a sort of educated guess about what you
expect. It is a statement used to predict the outcome of an experiment

Step-4. Test the hypothesis by experimentation.

 When you design an experiment, we are controlling the

(independent variables) and measuring (dependent).

 A basic experiment contains variables, which are factors you can

measure. The two main variables are the independent variable (the
one you control or change) and the dependent variable (the one you
measure to see if it is affected when you change the independent
variable).

Step5: Determine whether you accept or reject the hypothesis.

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Do the results support the hypothesis or not? Keep in mind, it’s okay if
the hypothesis is not supported, especially if you are testing a null
hypothesis. Sometimes excluding an explanation answers your question!
There is no “right” or “wrong” here. However, if you obtain an
unexpected result, you might want to perform another experiment.

Step6: Draw a conclusion and report the results of the experiment.

What good is knowing something if you keep it to yourself? You should

report the outcome of the experiment, even if it’s just in a notebook. What
did you learn from the experiment?

Step 1. Observe a phenomenon that has no good explanation

 He observed the number of death (mortality rate about 50%) due to

the case.

 What is the cause of particular effect? he Understood that it related

to drinking contaminated water provided by particular supplier in
London.

Step 2. Formulate a hypothesis

John Snow had long been skeptical of the then dominant miasma
theory that diseases like cholera were caused by a noxious form of foul
air:

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Miasma was considered to be a poisonous vapor or mist filled with
particles from decomposed matter (miasmata) that caused illnesses. The
Miasmatic position was that diseases were the product of environmental
factors such as contaminated water, foul air, and poor hygienic conditions.
Such infection was not passed between individuals but would affect
individuals who resided within the particular locale that gave rise to such
vapors. It was identifiable by its foul smell.

There was no proof miasma theory was true so Snow rejected the theory
and sought to find a proper one. When a virulent cholera epidemic broke
out in London in 1854, Snow investigated. Through interviews he
collected data about which houses cholera deaths occurred in. In his later
study the data was plotted in the form of a spot map, as shown.

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Fig 2 spot map of cholera deaths in London in 1854.

Here in John Snow's own words is the reasoning he went through to

develop his hypothesis:

On proceeding to the spot, he found that nearly all the deaths had taken
place within a short distance of the [Broad Street] pump. There were only
ten deaths in houses situated decidedly nearer to another street-pump. In
five of these cases the families of the deceased persons informed me that
they always sent to the pump in Broad Street, as they preferred the water
to that of the pumps which were nearer. In three other cases, the deceased
were children who went to school near the pump in Broad Street....

With regard to the deaths occurring in the locality belonging to the pump,
there were 61 instances in which I was informed that the deceased persons
used to drink the pump water from Broad Street, either constantly or
occasionally...

The result of the inquiry, then, is, that there has been no particular
outbreak or prevalence of cholera in this part of London except among the
persons who were in the habit of drinking the water of the above-
mentioned pump well.

On the basis of this evidence Snow concluded that drinking water from
the Broad Street well pump caused cholera. It was a radical hypothesis for
the time.

Step 3. Design an experiment(s) to test the hypothesis

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Snow then devised an experiment so simple it rings in the minds of
scientists to this day. The experiment was to remove the Broad Street
pump handle immediately. If the hypothesis was true this would stop the
cholera epidemic. Continuing the above quote:

he had an interview with the Board of Guardians of St James's parish, and

represented the above circumstances to them. In consequence of what he
said, the handle of the pump was removed on the following day.

Step 4. Perform the experiment(s)

The pump handle was removed. The epidemic ended. Deaths quickly
trailed off and fell to zero. Those who had fled the neighborhood moved
back and life soon returned to normal.

Step 5. Accept, reject, or modify the hypothesis

Since the epidemic had already started to fade it was not clear if the
experiment proved the hypothesis or not:

The report concluded that: Diseases which are communicated from person
to person are caused by some material which passes from the sick to the
healthy, and which has the property of increasing and multiplying in the
systems of the persons it attacks. In syphilis, smallpox, and vaccinia, we
have physical proof of the increase of the morbid material, and in other
communicable diseases the evidence of this increase, derived from the
fact of their extension, is equally conclusive. As cholera commences with
an affection of the alimentary canal, and as we have seen that the blood is

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not under the influence of any poison in the early stages of this disease.it
follows that the morbid material producing cholera must be introduced
into the alimentary canal [and] must, in fact, be swallowed accidentally,
for persons would not take it intentionally....

However, due to paradigm change resistance:

After the cholera epidemic had subsided, government officials replaced

the Broad Street Pump Handle. They had responded only to the urgent
threat posed to the population, and afterward they rejected Snow's theory.
To accept his proposal would be indirectly accepting the oral-fecal
method transmission of disease, which was too unpleasant for most of the
public.

Science soon accepted Snow's new theory and the field

of epidemiology was born.

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