Advance Epi & Direct Acyclic Graph

ADVANCE EPI & DIRECT ACYCLIC GRAPH
 Epi = upon (among)
 Demos = people
 Ology = science
 Epidemiology = the science which deals with what falls upon people…..
Epidemiology is concerned with the frequency and pattern of health events in a population:
Frequency refers not only to the number of health events such as the number of cases of
meningitis or diabetes in a population, but also to the relationship of that number to the size of
the population. The resulting rate allows epidemiologists to compare disease occurrence across
different populations.
Pattern refers to the occurrence of health-related events by time, place, and person. Time
patterns may be annual, seasonal, weekly, daily, hourly, weekday versus weekend, or any other
breakdown of time that may influence disease or injury occurrence. Place patterns include
geographic variation, urban/rural differences, and location of work sites or schools. Personal
characteristics include demographic factors which may be related to risk of illness, injury, or
disability such as age, sex, marital status, and socioeconomic status, as well as behaviors and
environmental exposures.
Application
Epidemiology is not just “the study of” health in a population; it also involves applying the
knowledge gained by the studies to community-based practice. Like the practice of medicine, the
practice of epidemiology is both a science and an art. To make the proper diagnosis and
prescribe appropriate treatment for a patient, the clinician combines medical (scientific)
knowledge with experience, clinical judgment, and understanding of the patient. Similarly, the
epidemiologist uses the scientific methods of descriptive and analytic epidemiology as well as
experience, epidemiologic judgment, and understanding of local conditions in “diagnosing” the
health of a community and proposing appropriate, practical, and acceptable public health
interventions to control and prevent disease in the community.
Epidemiology is the study of the determinants, distribution, and frequency of disease (who gets
the disease and why) I
epidemiologists study sick people I epidemiologists study healthy people I to determine the
crucial difference between those who get the disease and those who are spared I I
epidemiologists study exposed people I epidemiologists study non-exposed people I to determine
the crucial effect of the exposure
DR PURNIMA VERMA PHD Page 1

Two Broad Types of Epidemiology:
Descriptive epidemiology: examining the distribution of disease in a population, and observing

the basic features of its distribution
Analytic epidemiology: investigating a hypothesis about the cause of disease by studying how
exposures relate to disease
Advance epidemiology
“The study of the distribution and determinants of health-related states in specified populations,
and the application of this study to control health problems."
1. To describe the distribution and magnitude of health and disease problems in the population.
2. To identify the etiological factors – risk factors in the population.
3. To provide the data essential to planning, implementation and evaluation of services for
prevention, control and treatment of disease and to setting up of priorities for these services.
The ultimate aim of epidemiology is
 to eliminate or reduce health problem or its consequences
and
 to promote health and well-being of society as a whole.
Approach of an epidemiologist
 Asking questions
 making comparisons
● Asking questions may provide clues to cause or aetiology of disease e.g.
What is the event,
what is its magnitude,
where did it happen,
when did it happen,

who were affected,
why did it happen?
 Making comparisons will help draw inferences to support asking questions.
 This comparison may be:
● Between those with the disease and those without the disease;
● Those with risk factor and those not exposed to risk factor
 Endemic: constant presence of a disease in a given population
 epidemic: outbreak or occurrence of one specific disease from a single source, in a

group population, community, or geographical area, in excess of the usual level of
expectancy
 pandemic: epidemic that is widespread across a country, or large population, possible

worldwide
Three essential characteristics that are examined to study the cause(s) for disease in
analytic epidemiology are...
 Host
 Agent
 Environment

EPIDEMIOLOGICAL METHODS
The methods he employs can be classified as:
1. Observational studies
a. Descriptive studies
b. Analytical studies
– Case control studies
– Cohort studies
2. Experimental/interventional studies
– Randomized control studies
– Field trials
– Community trials
Descriptive observations pertain to the “who, what, where and when of health-related state
occurrence”. However, analytical observations deal more with the ‘how’ of a health-related event
occur.
Randomized control trial (often used for new medicine or drug testing), field trial (conducted on
those at a high risk of conducting a disease), and community trial (research on social originating
diseases)
Descriptive Studies
Steps in conducting a descriptive study.
Descriptive studies form the first step in any process of investigation.
These studies are concerned with observing the distribution of disease in populations.
1. Defining the population.
2. Defining disease under study.
3. Describing the disease.

4. Measurement of disease
5. Compare
6. Formulate hypothesis-
Defining the population. Defined population may be the whole population or a representative
sample.
 It can also be specially selected group such as age and sex groups, occupational groups,
hospital patients, school children, small community, etc.
 2. Defining disease under study.
 3. Describing the disease.
 Disease is examined by the epidemiologist by asking three questions:
 ● When is the disease occurring—time distribution?
 ● Where is it occurring—place distribution?
 ● Who is getting the disease—person distribution?
. Time Distribution
 Short-term fluctuations.
Common source epidemics
- single exposure/point source—bhopal tragedy
Propagated-infectious :Hep A
 Periodic fluctuations;
Seasonal –measles (early spring)
cyclic- ,, in pre-vaccinated era (peak 2-3 yr)
 Long-term or secular trends; diabetes, CVD
B. Place Distribution
 International variations:
Cancer of stomach very common in Japan

less common in US.
oral cancer- India
Breast cancer- Low-japan, high-western
 National variations, e.g. Distribution of fluorosis,
 Rural-urban differences, e.g.
CVD, Mental illness more common in urban areas.
Skin diseases, worm infestations more common in rural areas.
 Local distributions, e.g. Spot maps- John Snow in London to incriminate water supply
as cause of cholera transmission in London.
 C. Person Distribution
 Age: e.g.
 Measles is common in children,
 Cancer in middle age
 Degenerative diseases in old age.
 Sex:
 Women- Lung cancer-less
 Hyperthyroidism- more
 c. Social class- Diabetes, Hypertenson– upper class
. Measurement of disease- Mortality/ Morbidity
5. Compare- Between different population, subgroups
6. Formulate hypothesis. On basis of all data epidemiologist form hypothesis.
Case- control studies
 It start from effect and then proceed to cause
 Both exposure and outcome have occurred before start of the study

 The study proceeds backwards from effect to cause
 Select subjects based on their disease status.
A group of individuals that are disease positive (the "case" group) is compared
with a group of disease negative individuals (the "control" group).
 The control group should ideally come from the same population that gave rise to the
cases.
Basic steps in a case-control study
 1. Selection of cases and controls
 2. Matching
 3. Measurement of exposure
 4. Analysis and interpretation.
Case with lung Control without lung cancer

cancer
Smokers (less than 5 ) 33 (a) 55 (b)
Non-Smokers (less than 5 ) 2 (c) 27 (d)
The first step is to find out
1. Exposure rates among cases
=a/(ac) = 33/35 =94.2%

2. Exposure rate among the controls
=b/(bd) = 55/82 =67%
 If the exposure rate among the cases is more than the controls.
 We must see if the exposure rate among the cases is significantly more than the controls.
This is done by using the chi-square test
 It is significant if p is less than 0.05.
Odds ratio
 It is a measure of strength of association between the risk factor and outcome.
 The derivation of the odds ratio is based on three assumptions:
● The disease being investigated is relatively rare
● The cases must be representative of those with the disease
● The controls must be representative of those without the disease.
Odds ratio a.d/b.c
33X27/55X2 = 8.1
 People who smoke less than 5 cigarettes per day showed a risk of having lung cancer 8.1
times higher as compared to non-smokers.
 Case control studies are usually faster and more cost effective
 Sensitive to bias
 The main challenge is to identify the appropriate control group;
 The distribution of exposure among the control group should be representative of the
distribution in the population that gave rise to the cases.
Cohort Study
 It look at cause and proceed to effect
 study before the disease is manifest and proceed to study over a period of time for the
disease to occur.
 Cohort means a group of people sharing a common experience.

 Cohort studies are often prospective studies, they can be retrospective also, or a
combination of both prospective and retrospective components can be brought in.
 Randomization is a statistical procedure where
participants are allocated into groups called study and control groups to receive or not to receive
an experimental therapeutic or preventive procedure, intervention.
Randomization is an attempt to avoid bias and allow comparability.
 Study designs include
Concurrent parallel
Crossover type of study designs.
 In the former, study and control groups will be studied parallel whereas in the latter all
the participants will have the benefit of treatment after a particular period because the
control group becomes study group.
Types of randomized control studies are:
 Clinical trials, e.g. drug trials
 Preventive trials, e.g. trials of vaccines
 Risk factor trials, e.g. trials of risk factors of cardiovascular disease, e.g. tobacco use,
physical activity, diet, etc.
 Cessation experiments, e.g. smoking cessation experiments for studying lung cancer.

DIRECTED ACYCLIC GRAPH
A Dag Displays Assumptions About The Relationship Between Variables Often Called Nodes In
The Context Of Graphs.





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ADVANCE EPI & DIRECT ACYCLIC GRAPH

 Epi = upon (among)

DR PURNIMA VERMA PHD Page 1

Two Broad Types of Epidemiology:

Descriptive epidemiology: examining the distribution of disease in a population, and observing

2. To identify the etiological factors – risk factors in the population.

The ultimate aim of epidemiology is

 to eliminate or reduce health problem or its consequences

 to promote health and well-being of society as a whole.

● Asking questions may provide clues to cause or aetiology of disease e.g.

What is the event,

what is its magnitude,

where did it happen,

when did it happen,

DR PURNIMA VERMA PHD Page 2

who were affected,

why did it happen?

 Making comparisons will help draw inferences to support asking questions.

 This comparison may be:

 Endemic: constant presence of a disease in a given population

 epidemic: outbreak or occurrence of one specific disease from a single source, in a

 pandemic: epidemic that is widespread across a country, or large population, possible

DR PURNIMA VERMA PHD Page 3

The methods he employs can be classified as:

– Case control studies

– Randomized control studies

Steps in conducting a descriptive study.

Descriptive studies form the first step in any process of investigation.

1. Defining the population.

2. Defining disease under study.

3. Describing the disease.

DR PURNIMA VERMA PHD Page 4

 2. Defining disease under study.

 3. Describing the disease.

 Disease is examined by the epidemiologist by asking three questions:

 ● When is the disease occurring—time distribution?

 ● Where is it occurring—place distribution?

 ● Who is getting the disease—person distribution?

Common source epidemics

- single exposure/point source—bhopal tragedy

Seasonal –measles (early spring)

cyclic- ,, in pre-vaccinated era (peak 2-3 yr)

 Long-term or secular trends; diabetes, CVD

Cancer of stomach very common in Japan

DR PURNIMA VERMA PHD Page 5

less common in US.

oral cancer- India

Breast cancer- Low-japan, high-western

 National variations, e.g. Distribution of fluorosis,

 Rural-urban differences, e.g.

CVD, Mental illness more common in urban areas.

Skin diseases, worm infestations more common in rural areas.

 Measles is common in children,

 Cancer in middle age

 Degenerative diseases in old age.

 Women- Lung cancer-less

 c. Social class- Diabetes, Hypertenson– upper class