FAR EASTERN UNIVERSITY – DEPARTMENT OF MEDICAL TECHNOLOGY

Epidemiology

I. Introduction to Epidemiology

• Epidemiology is the study of the distribution (who has the problem), determinants (things that influence the
problem) of health problems or disease, and the application of this study to the control of diseases and other
health problems.
• Epidemiology can be used:
1. Used for surveillance of the incidence, frequency and distribution of disease
2. To study the progression of disease.
a. Studying risk factors (by determining who are likely to develop disease and under what condition)
• Nonmodifiable (age and sex) and modifiable (smoking)
b. For planning and implementing an intervention to prevent or reduce that risk or illness

Some Leading Causes of Death Worldwide

1. Heart Disease 5. Accidents/Injuries 9. Nephritis
2. Neoplasms 6. Diabetes mellitus 10. Septicemia
3. Cerebrovascular Disease 7. Influenza and pneumonia
4. Chronic Pulmonary Disease 8. Alzheimer’s Disease

Definition of terms
1. Numerator - the number of people to whom something happened (i.e. they got sick, died, etc.)
2. Denominator – Total observed population or population at risk for the event
3. Epidemic
• Disease or condition that affects a greater than expected number of individuals within a population,
community, or region at the same time
• Due to new agent, change in existing agent (infectivity, pathogenicity, virulence), change in number of
susceptible in the population or changes that affect transmission and growth of the agent
4. Endemic
• Normal occurrence of disease in a population
5. Pandemic
• Geographically widespread
• An epidemic that occurs in more than one continent
II. Fundamentals in Epidemiology
• Epidemiologic Triangle - A graphic demonstration of
the relationship between the:
1. Agent:
• Infectious (microbes - bacteria, viruses)
• Noninfectious (smoking, high bp, exposure to chemicals or radiation).
• An epidemiologist determines the primary agent, mode of transmission, geographic patterns
2. Hosts:
• Organisms (humans, animals) that may harbor a disease
• Factors that may affect susceptibility: age, gender, race/ethnicity, occupation, immune status, behavior
3. Environment
• Favorable conditions external to the host that allow the disease to be transmitted
• Population density, geography, season of the year, genetic effects / family history
4. Time:
• Duration of the illness or sickness till death or recovery occurs
• Incubation period (time between infection and appearance of symptoms occur)
• Latency period (Time between exposure and appearance of symptoms in chronic diseases)

AARON JAN PALMARES, RMT, MSMST_11.21.19 Page 1

 FAR EASTERN UNIVERSITY – DEPARTMENT OF MEDICAL TECHNOLOGY

• Mission of epidemiology
• Break the triangle to prevent disease completely or control the spread of disease
a. Understand what causes the disease
b. Determine the groups that are likely to get the disease
c. Determine the geographical factors that are conducive to the spread of disease
d. Address not just disease but mortality, hospitalization, disability, quality of life and health status

III. Measure of Disease Occurrence

A. Descriptive Epidemiology
• Understanding the disease by studying its pattern Example:
from the perspective of person, place, and time • You have been asked to investigate an event in
a. Dependent variable: The outcome which of the 2,220 people in the population, 32
b. Independent variable: Risk factors/ exposures
of them died.
1. Person - the study population (group of women,
• Your role as an epidemiologist is to ask questions
adolescents, etc.) about person, place and time.
a. age, gender, ethnicity, genetic predisposition • How do we ask questions? Through Survey:
b. concurrent disease, diet, exercise, smoking
a. -of survivors,
b. -of next-of-kin,
c. SES, education, occupation
2. Place - the geographical location
c. -of other related persons
a. School, worksite • With questions you learn that ...
b. presence or agents or vectors
a. Person: All were all exposed and at risk.
c. climate, geology The majority of people who died were
d. population density and economic development
children of 9 years and younger (when
e. nutritional and medical practices
compared to survivors).
3. Time - notion of time
b. Place: Most number of exposures were
a. seasonal patterns, temporal trends over time mostly in crowded urbanized areas.
b. calendar time, time since an event
c. Time: Rainy season, July to Dec, mostly
c. physiologic cycles & age (time since birth) children died after a 5 to 7 days of fever.

B. Prevalence and Incidence

Case 1. In the past month, Bgy. Sampaloc reported 5 new cases
of HIV/AIDS. This brings the new number of cases to 26 this year.
In Bgy. Quiapo, there were 10 new cases and over 100 total cases
during the same period
1. Prevalence (total no. of cases) = 26
2. Incidence (number of new cases) = 5
3. Mortality (number of deaths)

Case 2. In Bgy. Morayta, 9 new cases of HIV/AIDS were reported

on Nov. 21, 2019. This brings the total to 60 this year (2019). The
population is 150,000 and population at risk is 20,000. Prevalence ↑ by an ↑ in incidence,
↓ by mortality or cure
1. Prevalence
a. Point prevalence - No. of cases at a single point in time (E.g. November 21)
no. of cases (at a point in time) 9 6
• P= = x 100, 0000 = or 6 per 100,000 on Nov. 21
total observed population 150,000 100,000
b. Period prevalence - No. of existing cases during a period of time (year 2019)
no. of cases (during a period of time) 60 40
• P= = x 100, 0000 = or 40 per 100,000 in 2019
total observed population 150,000 100,000
c. Prevalence proportion
no. of cases 60 40
• P = = x 100, 0000 = or 40 per 100,000
total observed population 150,000 100,000

AARON JAN PALMARES, RMT, MSMST_11.21.19 Page 2

 FAR EASTERN UNIVERSITY – DEPARTMENT OF MEDICAL TECHNOLOGY

2. Cumulative Incidence (CI)

no. of new cases (in a period of time) 9 45
a. CI = = x 100, 0000 = or 45 per 100,000
no. of population at risk 20,000 100,000
3. Incidence Rate or Incidence Density
no. of new cases 9
a. IR = = x 100, 0000 = 45 new cases per 100,000 population per year
total no. person−time at risk 20,000
Suppose the actual time at risk for any person is 0.5 year (0.5 year/person)
no. of new cases 9 9
b. IR = = = x 100, 0000
total no. person−time at risk 20,000 ∗ 0.5y/p 10,000
= 90 new cases per 100,000 population per year
• Note: Prevalence and Incident Rate can be expressed as crude, specific and adjusted
4. Crude rate (raw rate) - Rate from the entire population under observation
no. of new cases of disease in a period of time 5 25
a. CI expressed as Crude Rate = = =
no. of population at risk 20,000 100,000
5. Specific rate - the specific subset of the population being observed is the focus
• The numerator and denominator are both subsets of the population according to:
• E.g. Age, Gender, Occupation, Race, Cause specific, Age-gender, etc.
6. Adjusted rate (standardized rate)
• A rate that is mathematically transformed to provide a summary rate for an observed population after a
specified characteristic are removed. The resulting rate is the estimated value
Distinguishing characteristics of Incidence and Prevalence
Type of Number Units Range Numerator Denominator Major Use
Proportion None 0 to 1 New cases Population at risk Research on causes prevention &
True Rate 1/time or t-1 0 to infinity New cases Person-time at risk treatment of disease
Proportion None 0 to 1 Existing cases Total Population Resource Planning

IV. Assessing Evidence of Disease Causation

A. Cause - Anything that brings about an effect or result. An event, condition or characteristic which plays an important
role in producing the disease. E.g. Cigarette smoking causes lung cancer
1. A Causal Association is an association between exposure and Outcome. An alteration in the exposure (events
or characteristics) in terms of frequency and quality is followed by a change in the outcome.
a. Direct cause - A factor that causes the problem without any intermediate step. Broken leg due to car
accident
b. Indirect cause - A factor that may cause the problem but with an intermediate factor or step
• E.g. Alcohol causes car accident which causes broken leg. Alcohol is the indirect cause
2. Attributes of a Cause
a. Association - a causal factor (X) must occur together with the outcome (Y); there is a statistical dependence.
b. Time order - the cause must precede the outcome (effect)
c. Direction - there should be a linear relationship between the cause and effect
3. Multiple Causation of Disease
a. Recognizes the role of the host, agent and environment in
bringing about the disease.
b. Disease cannot be attributed to a single factor
B. Koch’s Postulates (Causality of Infectious Diseases)
- 4 causal relationship between infectious agent and disease
1. An organism can be isolated from a host suffering
from the disease
2. The organism can be cultured in the laboratory
3. The organism causes the same disease when
introduced into another host
4. The organism can be re-isolated from that host

AARON JAN PALMARES, RMT, MSMST_11.21.19 Page 3

 FAR EASTERN UNIVERSITY – DEPARTMENT OF MEDICAL TECHNOLOGY

C. Bradford Hill Criteria for Assessing Causality

1. Strength of Strong associations are more likely to be causal than weak associations
Association (as measured by appropriate statistical tests)
2. Consistency of Association The repeatability of observation of an association in different populations
3. Specificity of Association The causal factor leads to a single effect and not multiple effect
4. Temporality (Proper The cause precedes the effect (outcome) in time.
Temporal Sequence)
5. Biological Gradient Increasing amount of exposure increases the risk
(dose-response relationship)
6. Plausibility The findings agree with currently accepted understanding of pathological
processes
7. Coherence A cause and effect interpretation do not conflict with the natural history
and biology of the disease.
8. Experimental Evidence The condition can be altered by an appropriate experimental regimen
9. Analogy Provides a source of more elaborate hypothesis about the associations
(causal relationship) under the study.
D. Relative ability of Different types
of study to prove Causation:
Ability to prove
Type of Study
Causation
1. Randomized Controlled Trials Strong
2. Cohort Studies Moderate
3. Case-control Studies Moderate
4. Cross-sectional studies Weak
5. Ecologic Studies Weak
6. Case Series and Reports Weak

E. How do epidemiologists identify “cause” of disease?

1. Generating and testing the specific hypothesis about factors that cause and prevent disease.
2. Causal Inference:
a. Determine if the observed value is valid or true. By eliminating Bias, Confounders and Random Error.
b. Assessing whether the exposure has actually caused the outcome (disease)
F. Evaluating the Role of Bias and Confounding
1. Types of Bias
a. Selection Bias - error that arises in the process of identifying and choosing the study population.
b. Information Bias - Misclassification bias due to recall bias and interviewer bias and difference in
ascertaining information between groups being compared.
2. Confounding
a. refers to the mixing of the effects of the exposure with that of a third factor.
b. Can lead to an overestimate or an underestimate the true association between exposure and disease
G. Necessary versus Sufficient cause
1. Necessary Cause: a cause that must be present for the disease to occur; the disease never develops without the
factor. All cases of the disease are exposed to the factor.
2. Sufficient Cause: a set of factors or causes that inevitably results in the disease; the disease always develops in
the presence of the factor. Complete causal mechanism that inevitably produces disease
H. Risk Factor
1. A factor (which could be an aspect of personal behavior or lifestyle, an environmental exposure, or an inborn or
inherited characteristic) which when present increases the likelihood of developing the disease compared to
when it is absent.
2. Not necessarily a causal factor (a risk marker)
3. If modifiable by intervention may reduce the probability of occurrence of disease

AARON JAN PALMARES, RMT, MSMST_11.21.19 Page 4