An introductory and comprehensive sketch

:Epidemiology and research methodology:

Dr. Srabana Misra Bhagabaty, MD

Department of Preventive Oncology
Dr.B.Borooah Cancer Institute
 Headlines
• Definitions of epidemiology
• Dawn of epidemiology: history
• Aims of epidemiology
• Components of basic epidemiology
• Types of epidemiological studies and methods
• Basic measurements in epidemiology
• Association and causation

Dr Srabana Misra Bhagabaty

 Classically speaking
Epidemiology derived from the word epidemic
Which is a very old word dating back to 3rd century
BC
• Epi = upon
• Demos = people
• Ology = science
• Epidemiology = the science which deals with
what falls upon people…..
• Bridge between biomedical, social and behavioral
sciences
Dr Srabana Misra Bhagabaty
 Old definitions
1.THE BRANCH OF MEDICAL SCIENCE WHICH
TREATS EPIDEMICS (Parkin,1873)

2.The science of the mass phenomena of

infectious diseases(Wade Hampton Frost ,1927)

3.The study of disease, any disease,as a mass

phenomenon (Greenwood,1934)

4.The study of the distribution and determinants

of disease frequency in man(Mac Mahon, 1960)

Dr Srabana Misra Bhagabaty

 1988: John M .Last definition

“ The study of the distribution

and determinants of health
related states or events in
specified populations and
application of this study to the
control of health problems”
Dr Srabana Misra Bhagabaty
 A Modern Definition

Study of the occurrence and distribution of

health-related diseases or events in specified
populations, including the study of the
determinants influencing such states, and the
application of this knowledge to control the
health problem
(Porta M, Last J, Greenland S. A Dictionary of Epidemiology, 2008)

Dr Srabana Misra Bhagabaty

 Father of modern epidemiology
>The first cases of cholera in England were
reported in1831
>Between 1831 and 1854, tens of thousands of people in
England died of cholera
> “Within 76 meters of the spot where Cambridge Street joins
Broad Street there were upwards of 500 fatal attacks of
cholera in 10 days
 Dr. Snow worked around the clock to track down information
from hospital and public records on when the outbreak began
and whether the victims drank water from the Broad Street
pump.

Ref:1

Dr Srabana Misra Bhagabaty

Dr Srabana Misra Bhagabaty
Dr Srabana Misra Bhagabaty
Dr Srabana Misra Bhagabaty
 Who is an epidemiologist ?
A professional who strives to study and control the
factors that influence the occurrence of disease or
health-related conditions and events in specified
populations and societies, has an experience
in population thinking and
epidemiologic methods, and is
knowledgeable about public health
and causal inference in health
(Porta M, Last J, Greenland S. A Dictionary of Epidemiology, 2008)

Dr Srabana Misra Bhagabaty

 Aims of Epidemiology
According to the International
Epidemiological Association(IEA)

> To describe the distribution and magnitude

of health and disease problems in human
populations
 To identify etiological factors (risk Factors) in
the pathogenesis of the disease
 To provide data essential to the planning
implementation and evaluation of services
for the prevention, control and treatment of
the disease and to the setting up of
priorities amongst those services

Dr Srabana Misra Bhagabaty

Ultimately

 To eliminate or reduce the health

problem or its consequences

 To promote the health and

wellbeing of the society as a whole

Dr Srabana Misra Bhagabaty

 Disease
Disease distribution
frequency

Main three
components of Disease
Three Components epidemiology
distribution
epidemiology

Disease
determinants
 Component:1 disease frequency

It is to measure the disease or health situation to

understand gravity/emergency of the issue

How it is measured: by biostatistical tools for

basic measurements in epidemiology in the form
of RATES and RATIOS

Dr Srabana Misra Bhagabaty

 Component:2 disease distribution
Descriptive epidemiology towards
hypothesis formulation
In terms of
Time: to understand disease fluctuation
patterns in relation to time i.e. short
term/periodic /long term
Place in terms of international, national,
rural-urban, local variations
Person in terms of age, sex, ethnicity,
marietal status, occupation, social status,
behaviour, stress and migration
Dr Srabana Misra Bhagabaty
 Component:3 Disease determinants
The real substance of epidemiology
analytical epidemiology

• Tests hypothesis
• Understanding determinants of diseases from
more solid proofs
• For formulating scientifically sound health
programs, interventions and policies

Dr Srabana Misra Bhagabaty

Types of epidemiological studies and
methods
Observational studies
a) Descriptive
b) Analytic
>ecological /correlation
>cross sectional/prevalence
>case control/ case reference
>cohort/follow up
Dr Srabana Misra Bhagabaty
EXPERIMENTAL /INTERVENTION STUDIES

a) Randomized
controlled trials
/clinical trials
b) Field trials /community
intervention trials
c) Community trials

Dr Srabana Misra Bhagabaty

 Basic measurements in
epidemiology
• Measurements in epidemiology: The scope is very
broad, unlimited and includes the following (ref-4)
1. Mortality
2. Morbidity
3. Disability
4. Presence/absence or distribution of the characteristics or
attributes as well as suspected environmental and other
factors of the disease
5. Medical needs, available facilities and utilization of these
medical or other health related services
6. Demographic variables

Dr Srabana Misra Bhagabaty

 BASIC REQUREMENTS IN
EPIDEMIOLOGICAL TESTS/
MEASUREMENTS

Is the quality control to reduce

errors

Dr Srabana Misra Bhagabaty

 By assuring

Sensitivity

1.Validity/ accuracy Specificity

2.Reliability/precision/reproducibility

Of the epidemiological measurements and tools

Dr Srabana Misra Bhagabaty

 VALIDITY
Validity refers to the closeness with which
measured values agree with “ true” values

Two components of validity are

A. Sensitivity
B. Specificity

Dr Srabana Misra Bhagabaty

 Sensitivity
Introduced by yerushalmy (ref:5) in 1940 as
statistical index of diagnostic accuracy

IT IS TRUE POSITIVE
Example of true positive : for example if a test
for a disease is 90 percent sensitive that means
90 out of 100 diseased people will show a positive
test result where as only 10 out of 100 disesed
people will show a negative result (false negative)
90 percent sensitivity

90 0ut of 100 diseased shows a positive test

10 out of
100
diseased
showed a
100 People with the disease
negative
result

Dr Srabana Misra Bhagabaty

 Specificity
TRUE NEGATIVE

Ability of a test to identify

correctly those who do not
have the disease

Dr Srabana Misra Bhagabaty

 90 percent specificity

90 0ut of 100 non- diseased shows a 10 out of

100 non-
negative test diseased
showed a
100 People without the disease
positive
result

Dr Srabana Misra Bhagabaty

 Calculation of validity
Test Diagnosis Total
Diseased Not Diseased

Positive A ( true positive) B ( false positive) A+B

Negative C ( false negative) D (true Negaive) C+D

Total A+C B+D A+B+C+D

Dr Srabana Misra Bhagabaty

Sensitivity =
true positive (A)
-------- ------------------------- ---------X 100
true positive (A)+ false negative(C)

Specificity=
true negative (D)
------------------------------------------------X 100
false positive( B) + true negative(D)
Dr Srabana Misra Bhagabaty
 Tools of measurement
expression of disease magnitude

1. Rates
2. Ratios
3. Proportion

Dr Srabana Misra Bhagabaty

 Before going to the basic tools of
measurements…
Numerator :
Numerator refers to the number of times an
event has occurred in a population, during a
specified time period.

Denominator :
Gives meaning to the numerator

Dr Srabana Misra Bhagabaty

 RATE
• Measures occurrence of some particular event
in a population during a given time period
• The epidemiologist has to choose an
appropriate denominator while calculating a
rate.
a) Related to the population
b) Related to the total events

Dr Srabana Misra Bhagabaty

 Related to the population
denominators
• Mid-year population
• Population at risk
• Person time
• Person distance
• Population sub groups

Dr Srabana Misra Bhagabaty

 Related to the total events
Related to the total events in stead of the total
Population

Example :
accidents rate calculation may have
denominators like per 100/1000/….vehicles
than total population as all population may
not use vehicle
Dr Srabana Misra Bhagabaty
Elements of RATE
• Numerator
• Denominator
• Time specification
• Multiplier

Expression of rate :
as per 1000 or some other round figures selected
according to convenience and to avoid fractions

Dr Srabana Misra Bhagabaty

 Categories of rate
• Crude rates/ unstandardized rates : actually
observed rates. Example: birth and death
rates.
• Specific rates : Actually observed rates due to
specific cause; specific groups; specific time
periods
• Standardized rates: these are obtained by
direct or indirect methods of standardization
Dr Srabana Misra Bhagabaty
 RATIO
• RELATION IN SIZE OF TWO RANDOM QUANTITIES
• THE NEMERATOR IS NOT A PART OF THE
DENOMINATOR
PROPORTION
A proportion is a ratio which indicates the
relation of a part of the whole. The numerator
is always included in the denominator
 Measurement of morbidity
Incidence
Number of new cases occurring in a defined
population during a specified period of time

Number of spells of sickness starting in a defined period

---------------------------------------------------------------------------X 100
Mean number of persons exposed to risk in that period

Uses of incidence: a) control disease

b) for research : etiology, pathogenesis disease distribution
efficiency of preventive and therapeutic measures
 Prevalence
Prevalence: All current (old and new) cases existing at a given point or over a
Period of time in a given population.
Types of prevalence :
POINT PREVELENCE
Number of all current cases of a specific disease existing at a given point of
time
-------------------------------------------------------------------------------------------------------
X100
Estimated population at the same point of time

PERIOD PREVELENCE:
Number on existing cases during a period
----------------------------------------------------------X100
Estimated mid-interval population at risk
Uses of prevalence:
a) Estimates the magnitude of health/ disease
problems in the community
b) Identify high risk populations
c) Administrative and planning purposes e.g hospital
beds, man powerneeds, rehabilitation facilities etc.

• Relation of incidence to prevalence :

• Prevalence= Incidence X Mean Duration
• P=IXD
 ASSOCIATION AND CAUSATION

• ASSOCIATION and CAUSATION : concurrence

of two variables more often than would be
expected by chanceCorrelation determines
the degree of associationCorrelation
coefficient varies from -1to +1 Correlation may
not measure risk.Causation implies correlation
but co-relation may not imply causation
 Types of association:

A) Spurious association:
B) Indirect association:
C) Direct association:
Criteria for judging causality:

>Temporal association :
>Strength of association:
>Specificity of association:
>Consistency of the association:
>Biological plausibility:
>Coherence of association:
 uses of epidemiology

• History : rise and fall of disease in the

population
• Community diagnosis
• Planning and evaluation
• Evaluation of individuals risks and chances
• Syndrome identification
• Completing the natural history of disease
• Searching for cause and risk factors
Dr Srabana Misra Bhagabaty
 References

1.Snow J. On the mode of communication of cholera. 2nd

ed. In: Snow on Cholera. (Reprint.) New York, New
York: Hafner Publishing Co., 1965. Available at
http://www.ph.ucla.edu/epi/snow.html.
2. Bumberg, M.S(1966).In:Chronic Diseases and Public
Health,Lilienfeld, et al (eds). John Hopkins
3. Park textbook of Preventive and Social Medicine: 21st
edition
4.Fox ,J.P etal(1970). Epidemiology : Man and disease,
New York, Macmillan
5. WHO(1959) Techn. Rep. Ser.,No. 164

Dr Srabana Misra Bhagabaty

following the story "Elephant's Child" in "Just So
Stories" Poem by Rudyard Kipling:

“I keep six honest serving-men

(They taught me all I knew);
Their names are What and Why and
When
And How and Where and Who”

Dr Srabana Misra Bhagabaty

Thank you
Dr Srabana Misra Bhagabaty