CHRONIC DISEASE EPIDEMIOLOGY

Causes of Death:
● ⅔ deaths due to non communicable diseases
● Many causes of death are due to non communicable diseases
○ Such as heart disease

U.S. Healthcare Costs in 2020:

● $3.8 trillion
● 17.7% of GDP
● Paid for by federal gov, households, private businesses, other

Infectious vs. Chronic:

● Infectious-
○ Incubation period, usually short
○ Causal agent- one
○ If source of infectious agent is found, outbreak can be stopped
● Chronic-
○ Diseases that last a year or longer and require ongoing medical attention or limit
daily activities or both
○ Causal agent- can be multifactorial
○ Chronic diseases are often brought on by behavioral, social, and genetic factors
that are not easily changeable

Major Chronic Diseases:

● CVD (cardiovascular disease)- disorders that reduce the blood supply to the heart
muscle
● Stroke- artery in the brain is either ruptured or clogged by a blood clot resulting in
interruption of the blood supply
● Cancer- uncontrolled growth and spread of abnormal cells
● Diabetes (Type II)- characterized by insulin resistance leading to hyperglycemia

Common risk factors in CVD, Cancer, and Diabetes:

● Smoking
● Poor diet
● Physical inactivity

Recommended Exercise Minimums:

● Moderate intensity
○ 30 min 5x/week
○ And muscle strengthening activities on 2 or more days/week
● Vigorous intensity
○ 25 min 3x/week
○ And muscle strengthening activities on 2 or more days/week
Data Sources:
● Vital stats (death certificates)
● Disease registries (cancer)
● Health surveys (BRFSS)
● Admin data (hospital discharge data)
● U.S. census

Have dietary interventions aimed at changing individual behavior been successful?

● NO the data does not show that education and awareness has had a significant impact
on diet
○ Government policy could be a solution

SCREENING
What is screening?
● The presumptive identification of unrecognized disease or defects by the application of
tests or examinations
● Detect asymptomatic
● Provide early treatment
● Improve prognosis

Examples of Screening Tests:

● Fasting blood sugar test
○ For diabetes
● Systolic/diastolic blood pressure
○ For hypertension
● Purified protein derivative skin test
○ For tuberculosis
● Mammography
○ For breast cancer
● Prostate-specific antigen
○ Prostate cancer
● Colonoscopy
○ Colon cancer
● Fecal occult blood test
○ Colorectal cancer

Characteristics of Good Screening Test:

● Simple
● Rapid
● Inexpensive
● Safe
● Acceptable
Types of Screening:
● Mass screening
○ Regardless of risk for having disease
○ For everyone
● Selective screening
○ Groups at higher risk of having the disease

Ethical Considerations:
● Screening is beneficial if…
○ Early treatment improves prognosis
○ Screened individuals receive treatment
● Other considerations
○ Cost-benefit ratio
○ severity/type of the condition
○ Prevalence of disease
○ Reliability
○ Validity

Reliability and validity:

● Reliability- ability of measuring instrument to give consistent results on repeated trials
(precisions)
● Validity- ability of measuring instrument to give a true measure of whatever is being
measured (accuracy)
● Want screening test to be both reliable and valid

Questions:
● Can screening be both reliable and invalid?
○ Yes
● Can a screening test be both unreliable and valid?
○ No

Gold standard (truth):

● A definitive diagnosis that has been determined by biopsy, surgery, autopsy, or other
method
● Provides a standard against which sensitivity (and specificity) are evaluated
Interpretations:
● Sensitivity- of those who have the disease, XX% tested positive with this test
○ __TP__ *100
(TP + FN)
● Specificity- of those who do NOT have the disease, XX% tested negative with this test
○ __TN__ *100
(TN + FP)
● Positive predictive value- of those who test positive, XX% actually have the disease
○ __TP__ *100
(TP + FP)
● Negative predictive value- of those who test negative, XX% truly do NOT have the
disease
○ __TN__ *100
(TN + FN)

Implications of False Positives and False Negatives:

● False positives
○ Unnecessary stress for the individual
○ Excess costs of further testing
○ Excess risks of unnecessary testing
● False negatives
○ Individuals that need further testing and treatment won’t receive it

SOURCES OF ERROR IN EPIDEMIOLOGIC RESEARCH-BIAS

Error:
● Random-
○ Fluctuation around the true value of a parameter (RR)- random and often due to
chance
○ Poor precision
○ Sampling error
○ Variability in measurement
● Systematic (bias)-
○ Systematic deviation of results from the truth
○ Conception or design of study
○ Collection, analysis, interpretation, reporting, publication or review of data

Bias definition:
● Any systematic error in the design, conduct or analysis of a study that results in a
mistaken estimate of an exposure’s effect on the risk of disease

Information Bias:
● Introduced as a result of measurement error in assessment of exposure and/or outcome
● Recall bias- seen in case-control studies
 ○ Those with disease more likely to remember exposure than those without
disease
● Interviewer bias- interviewers may probe more thoroughly for exposure information in
cases than in controls
● Surrogate Interview bias- surrogate may change exposure for spouse/parent
● Observer bias- person reading x-rays may look just a little harder to see if there is a
tumor there if exposure status is known

Technique to reduce Information Bias:

● Recall bias
○ Memory aids
○ Blind participants to study goals
○ Use work or medical records for exposure history
● Interviewer/observer bias
○ Blind to interviewers to subject’s status
○ Standardized training on study protocol and data collection forms
○ Use clear language in questionnaires
○ Blind research staff to status of study subject
○ Ask multiple sources to decrease surrogate bias

Selection bias:
● Error due to systematic differences in characteristics between those selected for study
and those not
● Can occur…
○ Before study begins
○ During recruitment
○ During follow-up
● Loss to follow-up- seen in cohort and RCT
○ Problem when we have more dropping out in one group than the other

Selection Bias- Healthy Worker Effect:

● Observation that employed populations tend to have a lower mortality experience than
the general population
● Often seen in occupational studies- exposed persons are employed and unexposed
come from general population
● May impact occupation mortality studies:
○ Persons with shortened life expectancy are less likely to be employed than
healthy persons; general population includes employed and unemployed persons
so the mortality rate may be higher than if just looking at employees
○ Any excess mortality due to exposure associated with occupation is harder to
detect when healthy worker effect is present

Selection Bias- No Response:

 ● Subjects who are eligible for the study but choose not to participate may be different
from those who choose to participate
● Loss to follow-up is included

Techniques to reduce Selection Bias:

● Healthy worker effect
○ Use employed workers for the unexposed group rather than the general
population; they should be like the exposed workers just don’t have the exposure
● Loss to follow-up and Nonresponse bias
○ Provide incentives to have high participation rate
■ Entering study
■ Follow-up
○ Good tracking for study participants so not lost

SOURCES OF ERROR IN EPIDEMIOLOGIC RESEARCH- CONFOUNDING

Definition of a Confounder:
● Another factor that influences the relationship between the exposure and outcome
● factor/variable which distorts the estimate of association between the exposure and
outcome
● Presence of a confounder can
○ Overestimate relationship
○ Underestimate relationship
○ Reverse relationship

Criteria to be a Confounder:
● Must be a risk factor for outcome
● Must be associated with exposure
● Must NOT be an intermediate step in casual path between exposure and outcome

What does it mean to “account for” or “control for” a confounder?

● AKA “adjusting for”
● Remove the effect of the confounder on the relationship between exposure and outcome

How different should the stratum-specific measures be from the crude in order to conclude
confounding?
● Investigator must decide if the stratum-specific measures of association are meaningfully
different from the crude
○ Judgement call
○ Some epidemiologists use the 10% rule

How can we control for confounding?

● Prevention strategies
○ Randomization- particularly for unknown factors
 ○ Restriction- restrict based on confounding variable (if gender is confounding
variable, restrict to females only)
○ Matching- match on the confounding variable (if gender is confounding variable,
match on gender)
● Analysis strategies
○ Multivariable techniques- adjust using modeling techniques
○ Stratification- analyze in subgroups (males/females)
● Information bias, selection bias, and confounding: confounding is the ONLY bias which
can be controlled for during analysis

Control for Confounding using Multivariable Technique:

● Crude OR/RR- simple calculation that you know that you know from 2x2 table with just
the exposure and outcome in the model
● Adjusted OR- done with software and has the exposure, outcome, and the confounder in
analysis
● How do you know if the variable is a confounder?
○ Adjusted OR/RR is > 10% larger or >10% smaller than the crude OR/RR

Control for Confounding using Stratification Technique:

● Calculate the Crude RR just like with multivariable technique and instead of calculated
an adjusted RR
● Stratify the 2x2 table data into the two levels of the confounder
○ i.e.) you will have two tables, one for smokers and one for nonsmokers
● Calculate RR for smokers and a RR for nonsmokers- these are called stratum-specific
RRs
● Compare the two stratum-specific RR to each other- should be similar
● Compare the stratum specific RR to crude- look for meaningful difference

Effect Modification:
● Is present when the association between an exposure and an outcome is different for
different levels of a third factor (think confounder but it’s not)
● A true biological phenomenon
○ Not a type of bias
● Synonyms- interaction, synergism

Steps for identifying effect modification:

● Calculate the crude measure of association (i.e. RR, OR)
● Stratify the data into the levels of the potential effect modifier
● Calculate the measure of association for each level of the potential effect modifier
● Compare the stratum-specific measures to each other
○ If they are different, effect modification is present, report results stratified by the
effect modifier
Review of Effect Modification:
● Association between an exposure and an outcome is different for different levels of a
third factor
● Steps for identifying effect modification
○ Stratify by the levels of the potential effect modifier
○ If the stratum-specific measures are different from each other, effect modification
is present
■ Report results stratified by the effect modifier

Confounding vs. Effect Modification:

● Confounding-
○ A bias that should be prevented or removed
○ Need to remove the effect of the third variable
○ May or may not be present depending upon study design
● Effect Modification-
○ A finding should be described
○ Need to report the effect of the third variable
○ Exists independently of study and study design

Stratified Analysis:
● Two goals-
○ Evaluate and describe effect modification
■ Report the effect of the third variable
○ Evaluate and remove confounding
■ Take out the effect of the third variable
● Loof for effect modification first; if not present, then assess confounding

CAUSALITY
Questions to ask:
● Could association have been observed by chance?
● Could association be due to bias?
○ Systematic error that can affect the MOA
● Could other confounding variables have accounted for the association?
○ Other variables that affects the MOA
● Does association represent cause-effect?

Causality in Epi Studies:

● Smoking and Health, 1964 Surgeon General’s report
○ Presented several criteria for evaluation of a causal association
● A. B. Hill’s criteria of causality
○ Expanded list of causal criteria
● Leon Gordis, Epidemiology
Guidelines for Judging whether an observed association is causal (Hill’s Criteria):
● Temporal relationship
○ Cause observed before effect (exposure before disease)
● Strength of the association
○ Strong associations give support to causal relationship
● Replication of the findings (Consistency)
○ Association observed repeatedly in different study designs, different populations
● Dose-response relationship (Biologic Gradient)
○ As the dose of exposure increases, the risk of disease also increases
● Biologic plausibility
○ Fits with the biological knowledge of the day
● Consideration of alternative explanations (Coherence)
○ Other explanations have been considered
● Consistency with other knowledge (Analogy)
○ Active smoking/lung cancer and passive smoking/lung cancer
● Cessation of exposure (Experiment)
○ Does the prevention of the exposure effect the frequency of the outcome
● Specificity of the association
○ Any exposure may give rise to only a single outcome (infectious vs noninfectious)

Multifactorial (Multiple) Causality:

● Involve more than one causal factor
○ Examples of multiple causal factors in etiology of many chronic diseases include
■ Environmental exposures
■ Family history
■ Lifestyle characteristics
■ Other factors

Types of Causal Relationships:

● Necessary and sufficient
● Necessary but not sufficient
● Sufficient but not necessary
● Neither sufficient nor necessary

COVID-19 OMICRON VARIANT OF CONCERN

How will we beat COVID-19?
● Prevention
● Treatment

COVID-19 Variants and why they are important:

● Delta variant- is still responsible for most covid-19 infections worldwide
● Omicron variant- new variant
COVID-19 Omicron Variant:
● Descriptive epidemiology
○ Person- persons who live in or who have traveled to and from South Africa within
the last 14 days
○ Any other characteristics, too soon to say, but does appear that reinfection is
occurring
○ Place: South Africa- the U.S. has not diagnosed any cases of COVID-19 as
being the omicron variant but 2 cases diagnosed in Canada
○ Time-first reported to WHO on Nov 24, 2021 from South Africa; the first
confirmed case of COVID-19 caused by the Omicron variant was from a
specimen collected on Nov 11, 2021
○ Came to the attention of WHO because of the significant rise in the cases
(incidence) in South Africa due to Omicron
○ What proportion of cases in South Africa are due to Omicron?
■ Unknown due to lack of PCR testing
○ Descriptive quantitative measure that’s important- incidence
● Analytical epidemiology
○ Too early

Omicron Variant:
● Large number of mutations
○ Increased risk of reinfection compared to other variants of concern (VOC)
○ Delta variant is considered a VOC
● What is a SARS CoV-2 variant of concern?
○ Increases transmissibility or detrimental change in epidemiology
○ Increase in virulence or change in clinical disease presentation
○ Decrease in the effectiveness of public health and social measures or vaccines,
therapeutics
● Transmissibility
○ Unclear whether Omicron is more transmissible than other variants (Delta)
○ Studies underway
● Severity of Disease
○ Unclear whether Omicron causes more severe case of the disease
○ South Africa has seen increasing hospitalization rates— could be due to
increased number of persons with COVID-19
○ Initial reported cases were among university students
● Effectiveness of prior SARS CoV-2 infection
○ Preliminary evidence indicates increased risk of reinfection
● Effectiveness of vaccine- unclear
● Effectiveness of current tests- PCR tests can detect infection with Omicron variant
● Effectiveness of current treatments- corticosteroids and IL6 receptor blockers are
effective for managing patients with severe COVID-19
CDC Response:
● No cases of Omicron variant reported in U>S.
● Traveler restrictions into the U>S> (Presidential Proclamation)
○ Suspends entry into the country of non U.S. citizens who were physically present
in these countries during the 14 days prior to entering the U.S.
■ Botswana, Eswatini, Lesotho, Malawi, Mozambique, Namibia, South
Africa, Zimbabwe
○ U.S. citizens who have been in one of these countries will be allowed to enter the
U.S.

EPIDEMIOLOGY: THE PROFESSION

Epidemiology as a Profession:
● Discuss areas of specialization within epidemiology
● Discuss career opportunities
● Internships and fellowships available for undergraduate students and graduates
● Discuss epidemiology organizations and journals that publish articles on epidemiology
● Resources

Epidemiology and Specializations:

● Due to the COVID-19 pandemic, epidemiologists and epidemiology because household
words
● “Armchair” epidemiologists bound
● As scientists, the work of epidemiologists has been scrutinized in real time ina world
expecting 100% accuracy
● Areas of specialization
○ Infectious diseases- investigators of food borne/ water borne diseases,
communicable diseases such as TB, COVID-19, and nosocomial diseases

Other areas of Specialization:

● Pharmacoepidemiology
● Environmental
● reproductive/ perinatal
● Social
● CVD
● genetic/ molecular
● Injury
● Aging
● Life course
● Nutrition
● Etc.
Career opportunities for Master’s trained:
● Health department- state, country, local
● Non-profit organizations
● Program evaluation and needs assessment
● Surveillance workers
● Research associates
● Doctors without borders

Career opportunities for Doctoral trained:

● Academia
● Pharmaceutical industry
● Biotech firms
● Consulting
● Federal employment
● WHO

State and local Health Departments:

● Investigate local outbreaks of disease
○ Food borne
○ Vector-borne
○ Disease clusters
○ Communicable diseases in schools
● Assist local hospitals and other health care providers with infection control
● Design and implement intervention and prevention programs for chronic disease control
● Implement health-related mandates issued by executive and legislative branches of
government

U.S. Government Agencies:

● CDC
○ Program administration
○ Research
○ “Shoe leather” data collection activities (personally collecting data rather than
relying on reports from others)
○ EIS (Epidemic Intelligence Service) - search for EIS
● NIOSH
○ Branch of CDC
○ Assures the health and safety of US workers- monitor workplace injuries,
women’s reproductive hazards, lineman’s electrocution hazards, construction
workers’ fall hazards, occupational exposures— benzene, formaldehyde,
asbestos

Organizations and Journals for Epidemiologists:

● American College of Epidemiology (ACE) (1979)
○ Members apply and are chosen based on select criteria
 ○ Criteria are used to address professional concerns in the field and provide
professional development
● Society for Epidemiologic Research (SER) (1968)
○ Organization for sharing the latest epidemiologic research
○ Advances scientific development – trains epidemiologist on latest epidemiologic
methods
○ American Journal of Epidemiology (AJE) is affiliated with SER
● American Public Health Association (APHA); Epidemiology Section (EPI)
○ Researchers and work in academic settings
○ Practice-based and work in health departments
○ Critical to APHA evidence-based policy development
○ American Journal of Public Health (AJPH) –affiliated with APHA

Employment Opportunities:
● Data from the BUreau of Labor Statistics
○ Need a master’s
○ Median salary (2020) $74,560
○ Job outlook: 30% increases in available positions approx. 900 available each
year due to COVID-19 retiring workforce, and changing occupation
○ Information for consumer